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Questions 149

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Question 1 of 5

The nurse is caring for a child in a plaster-of-Paris hip spica cast. To facilitate drying, the nurse should:

Correct Answer: C

Rationale: Turning the child every 2 hours ensures even drying of the cast and prevents pressure sores, promoting comfort and healing.

Question 2 of 5

The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is:

Correct Answer: B

Rationale: Mental confusion in diabetes insipidus may indicate severe dehydration or electrolyte imbalance, so checking vital signs is the priority to assess stability.

Question 3 of 5

A client in cardiac arrest shows to be in torsades de pointes, and magnesium sulfate is ordered STAT. The priority nursing intervention is

Correct Answer: A

Rationale: Magnesium sulfate for torsades de pointes can cause bradycardia and respiratory depression, requiring close monitoring.

Question 4 of 5

While administering a chemotherapeutic vesicant, the nurse notes that there is a lack of blood return from the IV catheter. The nurse should:

Correct Answer: A

Rationale: Lack of blood return suggests possible extravasation of a vesicant, which can cause tissue damage; stopping the infusion immediately prevents further harm.

Question 5 of 5

The nurse asks the client with an epidural anesthesia to void every hour during labor. The rationale for this intervention is:

Correct Answer: C

Rationale: Epidural anesthesia can diminish bladder sensation, increasing the risk of urinary retention, so hourly voiding is encouraged.

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