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Questions 158

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Question 1 of 5

The nurse caring for a client in shock recognizes that the glomerular filtration rate of the kidneys will fail if the client's mean arterial pressure falls below which of the following levels?

Correct Answer: D

Rationale: A mean arterial pressure (MAP) below 80 mmHg compromises renal perfusion, leading to glomerular filtration failure. Higher MAPs (A, B,
C) maintain adequate kidney function.

Question 2 of 5

A 2-year-old boy is in the hospital outpatient department for observation after falling out of his crib and hitting his head. The nurse calls the physician to report:

Correct Answer: D

Rationale: Perineal irritation needs to be addressed, but it is probably not necessary to call the physician. This fall in pulse rate remains within normal limits and is probably insignificant. It is important to monitor for continued change. This rise in pulse rate is probably not significant, but it is important to monitor for continued change. This temperature is above normal limits and needs medical investigation. It may or may not be related to the head injury.

Question 3 of 5

A registered nurse is trying to determine the appropriate care that she should provide for her obstetrical clients. Which of the following documents is considered the legal standard of practice?

Correct Answer: A

Rationale: The state nursing practice act determines the standard of care for the professional nurse. AWHONN Standards are published as recommendations and guidelines for maternal-newborn nursing. American Nurses' Association Standards are published as recommendations and guidelines for maternal-child health nursing. The International Council of Nurses' Code emphasizes the nurse's obligations to the client rather than to the physician. It is published as recommendations and guidelines by the international organization for professional nursing.

Question 4 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.

Question 5 of 5

A child becomes neutropenic and is placed on protective isolation. The purpose of protective isolation is to:

Correct Answer: A

Rationale: The child no longer has normal white blood cells and is extremely susceptible to infection, necessitating protective isolation.

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