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Questions 158

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Extract:


Question 1 of 5

The client is admitted with a diagnosis of hypovolemic shock. Which fluid is most appropriate for initial resuscitation?

Correct Answer: A

Rationale: 0.9% Normal saline is the preferred isotonic fluid for initial resuscitation in hypovolemic shock to restore intravascular volume. Dextrose is hypotonic, 3% saline is hypertonic, and lactated Ringer’s is used in specific cases like burns.

Question 2 of 5

A client confides to the nurse that he tasted poison in his evening meal. This would be an example of what type of hallucination?

Correct Answer: B

Rationale: Auditory hallucinations involve sensory perceptions of hearing. Gustatory hallucinations involve sensory perceptions of taste. Olfactory hallucinations involve sensory perceptions of smell. Visceral hallucinations involve sensory perceptions of sensation.

Question 3 of 5

A client with vaginal cancer is being treated with a radioactive vaginal implant. The client's husband asks the nurse if he can spend the night with his wife. The nurse should explain that:

Correct Answer: D

Rationale: Radioactive implants emit radiation posing a risk to others. Visitation is limited to short periods (e.g. 30 minutes) to minimize radiation exposure. The other options do not address the safety concern related to radiation.

Question 4 of 5

The nurse is assessing a trauma client in the emergency room when she notes a penetrating abdominal wound with exposed viscera. The nurse should:

Correct Answer: B

Rationale: Exposed viscera should be covered with sterile saline-soaked gauze to keep them moist and prevent infection until surgical repair. Replacing contents or using non-sterile/petroleum dressings is unsafe.

Question 5 of 5

The client has an order for Garamycin (gentamicin) to be administered. Which lab test should be done before beginning the medication?

Correct Answer: B

Rationale: Gentamicin, an aminoglycoside, is nephrotoxic. Serum creatinine is monitored before administration to assess baseline kidney function, as impaired renal function increases toxicity risk. Hematocrit, white cell count, and BUN are less specific for gentamicin.

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