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Questions 149

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Question 1 of 5

The nurse is caring for a client after he experienced a seizure (postictal). Which intervention would the nurse expect not to perform?

Correct Answer: A

Rationale: During the postictal phase, the client needs rest and monitoring, not immediate return to pre-seizure activity, which could be unsafe.

Question 2 of 5

A client with end-stage renal failure receives hemodialysis via an arteriovenous fistula (AV) placed in the right arm. When caring for the client, the nurse should:

Correct Answer: C

Rationale: Auscultating for a bruit confirms AV fistula patency, which is critical for hemodialysis.

Question 3 of 5

A client with a total knee replacement has a CPM (continuous passive motion device) applied during the post-operative period. Which statement made by the nurse indicates understanding of the CPM machine?

Correct Answer: C

Rationale: Pain during CPM use may indicate improper settings or complications, requiring physician notification.

Question 4 of 5

A client weighing 150 pounds has received burns over 50% of his body at 1200 hours. Using the Parkland formula, calculate the expected amount of fluid that the client should receive by 2000 hours.

Correct Answer: B

Rationale: Parkland formula: 4 mL × kg × % TBSA. Weight = 150 lb ÷ 2.2 = 68 kg. 4 × 68 × 50 = 13,600 mL total. Half (6,800 mL) is given in the first 8 hours (1200 to 2000).

Question 5 of 5

The nurse identifies ventricular tachycardia on the heart monitor. The nurse should immediately:

Correct Answer: C

Rationale: Ventricular tachycardia requires immediate treatment with an antiarrhythmic like lidocaine to restore normal rhythm.

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