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Questions 158

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Question 1 of 5

The client returns to the recovery room following repair of an abdominal aneurysm. Which finding would require further investigation?

Correct Answer: B

Rationale: Urinary output of 20 mL/hour is below the expected minimum of 30 mL/hour, indicating potential renal compromise or hypoperfusion, common risks after aneurysm repair. This requires further investigation. The other findings are within acceptable post-operative ranges.

Question 2 of 5

Which of the following combinations of foods is appropriate for an eight-month-old infant?

Correct Answer: C

Rationale: Rice cereal, bananas, and strained carrots are developmentally appropriate, easily digestible foods for an eight-month-old, unlike the other options, which include choking hazards or inappropriate items like whole milk.

Question 3 of 5

Nursing care for the parents of a child with a congenital heart defect would include:

Correct Answer: B

Rationale: It is important to discuss with parents the need to treat the child as they would any other children, but they must be truthful and honest with the child about the heart defect. As the child grows older, explanations can go into greater depth. Parents of children with congenital heart defects go through a grieving process over the loss of their 'healthy' child. The nurse needs to recognize these feelings and give the parents a role in the child's care when they are ready. Anger and resentment are normal feelings that must be dealt with appropriately. Parents may go through a second grieving process after the repair of the cardiac defect. During this grieving period, they mourn the loss of the 'defective' child who now may be essentially 'normal.'

Question 4 of 5

The nurse is teaching a client with a new colostomy about appliance care. Which instruction should be included?

Correct Answer: B

Rationale: Emptying the colostomy pouch when one-third to one-half full prevents leakage and skin irritation. Changing every 12 hours is excessive, soap may leave residue, and lotion can interfere with adhesion.

Question 5 of 5

The client is admitted with a suspected subarachnoid hemorrhage. Which assessment finding is most concerning?

Correct Answer: A

Rationale: A blood pressure of 180/100 mmHg is concerning in subarachnoid hemorrhage, as hypertension can increase the risk of rebleeding or exacerbate intracranial pressure. Normal heart rate, clear CSF, and reactive pupils are less urgent.

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