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Questions 158

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Question 1 of 5

The nurse is caring for a client with scalding burns across the face, neck, upper half of the anterior chest, and entire right arm.

Correct Answer: 32

Rationale: Rule of nines: face (4.5%), neck (4.5%), upper half anterior chest (9%), right arm (9%) = 4.5 + 4.5 + 9 + 9 = 27%. The closest answer is 32% (
C), possibly due to rounding or partial overlap.

Question 2 of 5

As a postoperative cholecystectomy client completes tomorrow's dinner menu, the nurse knows that one of the following meal choices will best provide the essential vitamin(s) necessary for proper tissue healing?

Correct Answer: D

Rationale: This meal choice provides more of the vitamins A, D, and K than of vitamin C. This meal choice provides more of the vitamins A, B12, and D than of vitamin C. This meal choice provides more of the vitamins A, B1 (thiamine), niacin, and microminerals than of vitamin C. This meal choice provides foods rich in vitamin C, which are essential in tissue healing.

Question 3 of 5

A 35-year-old primigravida comes to the clinic for her first prenatal visit. The midwife, on examining the client, suspects that she is approximately 11 weeks pregnant. The pregnancy is positively confirmed by finding:

Correct Answer: B

Rationale: Chadwick's sign is a presumptive sign of pregnancy. The coloration may not subside from past pregnancy or could be caused by other situations that create vasocongestion. FHR (movement) observed DISTINCT on ultrasound is a positive diagnosis of pregnancy. Enlargement of the uterus may be due to fibroids or infection. It is considered a probable sign. Breast tenderness and enlargement is a presumptive sign because it may be due to other conditions, such as premenstrual changes.

Question 4 of 5

A 1000-mL dose of lactated Ringer's solution is to be infused in 8 hours. The drop factor for the tubing is 10 gtt/mL. How many drops per minute should the nurse administer?

Correct Answer: D

Rationale: 20.8, or 21 gtt/min.

Question 5 of 5

A client is receiving IV morphine 2 days after colorectal surgery. Which of the following observations indicate that he may be becoming drug dependent?

Correct Answer: D

Rationale: Frequent requests for pain medication do not necessarily indicate drug dependence after complex surgeries such as colorectal surgery. Sleeping after receiving IV morphine is not an unexpected effect because the pain is relieved. A person may be in pain even with normal vital signs. A subtle sign of drug dependency is the tendency for the person to appear more euphoric than relieved of pain.

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