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Questions 149

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Question 1 of 5

The nurse caring for the child with a large meningomylocele is aware that the priority care for this client is to:

Correct Answer: A

Rationale: Moist, sterile gauze prevents infection and drying of the meningomyelocele defect.

Question 2 of 5

The nurse is caring for a client with epilepsy who is to receive Dilantin 100 mg IV push. The client has an IV of D51/2NS infusing at 100 mL/hr. When administering the Dilantin, the nurse should first:

Correct Answer: C

Rationale: Dilantin is incompatible with dextrose solutions (D51/2NS), causing precipitation. Flushing with normal saline ensures compatibility and prevents complications.

Question 3 of 5

In planning care for the patient with ulcerative colitis, the nurse identifies which nursing diagnosis as a priority?

Correct Answer: C

Rationale: Fluid volume deficit is a priority in ulcerative colitis due to frequent diarrhea, which can lead to dehydration.

Question 4 of 5

The nurse is assessing the arterial blood gases (ABG) of a chest trauma client with the results of pH 7.35, PO2 85, PCO2 55, and HCO3 27. These ABG values indicate that the client is in:

Correct Answer: C

Rationale: pH 7.35 is normal, PCO2 55 is elevated (indicating respiratory acidosis), and HCO3 27 is slightly elevated, suggesting compensation. This is compensated respiratory acidosis, likely due to hypoventilation from chest trauma.

Question 5 of 5

A client is prescribed heparin 5,000 units subcutaneously every 12 hours for deep vein thrombosis prophylaxis. The pharmacy dispenses a vial containing 10,000 units/1 ml. How many milliliter(s) of heparin should the nurse administer?

Correct Answer: 0.5 mL

Rationale: Dose: 5,000 units. Concentration: 10,000 units/mL. Volume = 5,000 ÷ 10,000 = 0.5 mL per dose.

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