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Questions 158

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Question 1 of 5

The client is prescribed ipratropium (Atrovent) and albuterol (Proventil) via inhaler. Which instruction should the nurse include?

Correct Answer: A

Rationale: Albuterol, a bronchodilator, is used first to open airways, followed by ipratropium, an anticholinergic, to maintain bronchodilation. Simultaneous or single daily use is incorrect.

Question 2 of 5

The nurse is interviewing a client with a diagnosis of possible abdominal aortic aneurysm. Which of the following statements will be reflected in the client's chief complaint?

Correct Answer: D

Rationale: (A, B,
C) These complaints are not specific signs and symptoms associated with abdominal aortic aneurysm. If symptoms are present, the aneurysm is expanding or rupture is imminent. Many clients may experience no symptoms. The only symptom may be a pulsation noted in the abdomen in the reclining position.

Question 3 of 5

Which of the following findings would necessitate discontinuing an IV potassium infusion in an adult with ketoacidosis?

Correct Answer: A

Rationale: Adequate renal flow of 30 mL/hr is a necessity with potassium infusions because potassium is excreted renally. Because potassium level will decrease during correction of diabetic ketoacidosis, potassium will be infused even if plasma levels of potassium are normal. A small T wave is normal and desired on the electrocardiogram. A tall, peaked T-wave could indicate overinfusion of potassium and hyperkalemia. Glucose levels of <200 are desirable.

Question 4 of 5

A 9-week-old female infant has a diagnosis of bilateral cleft lip and cleft palate. She has been admitted to the pediatric unit after surgical repair of the cleft lip. Which of the following nursing interventions would be appropriate during the first 24 hours?

Correct Answer: B

Rationale: Placing the infant on her abdomen may allow for injury to the suture line. Elbow restraints prevent the infant from touching the suture line and yet leaves hands free. The suture line is cleaned as often as every hour to prevent crusting and scarring. Sucking of a bottle or pacifier places pressure on the suture line and may delay healing and cause scarring.

Question 5 of 5

A client with a history of Crohn's disease is admitted with a small bowel obstruction. The nurse should give priority to:

Correct Answer: A

Rationale: Small bowel obstruction in Crohn's disease can cause fluid loss through vomiting or sequestration, making monitoring for dehydration the priority to prevent hypovolemia.

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