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Questions 148

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Question 1 of 5

The nurse is caring for a client receiving IV vancomycin. The trough level is 14 mcg/mL. The next dose is now due. What is the correct response by the nurse?

Correct Answer: A

Rationale: A vancomycin trough of 14 mcg/mL is within the therapeutic range (10-20 mcg/mL), so the next dose can be given as ordered.

Question 2 of 5

The physician has made a diagnosis of 'shaken child' syndrome for a 13-month-old who was brought to the emergency room after a reported fall from his highchair. Which finding supports the diagnosis of 'shaken child' syndrome?

Correct Answer: C

Rationale: Retinal hemorrhages are a hallmark of shaken baby syndrome due to the shearing forces from violent shaking causing bleeding in the retina.

Question 3 of 5

The charge nurse in a cardiac ICU is precepting a student nurse. Which action by the student nurse requires immediate intervention by the charge nurse?

Correct Answer: B

Rationale: Lifting the urinary catheter bag above the bladder risks backflow of urine, increasing infection risk, and requires immediate intervention.

Question 4 of 5

A client with newly diagnosed type I diabetes mellitus is being seen by the home health nurse. The physician orders include: 1,200-calorie ADA diet, 15 units of NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the client at 5 PM, the nurse observes the man performing a blood sugar analysis. The result is 50 mg/dL. The nurse would expect the client to be

Correct Answer: A

Rationale: symptoms of hypoglycemia, normal blood sugar 70-110 mg/dL

Question 5 of 5

A client with chest pain is scheduled for a heart catheterization. Which of the following would the nurse include in the client's care plan?

Correct Answer: D

Rationale: During heart catheterization, the client may be asked to cough or breathe deeply to facilitate dye movement or assess respiratory response, a key part of preparation.

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