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Questions 149

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Extract:


Question 1 of 5

The nurse is caring for an infant receiving intravenous fluid. Signs of fluid overload in an infant include:

Correct Answer: B

Rationale: Fluid overload in infants can cause increased heart rate and blood pressure due to increased intravascular volume.

Question 2 of 5

The nurse is monitoring a client with a history of stillborn infants. The nurse is aware that a nonstress test can be ordered for this client to:

Correct Answer: D

Rationale: A nonstress test assesses fetal well-being by monitoring fetal heart rate in response to movement, particularly in high-risk pregnancies.

Question 3 of 5

How many hours of activity per day are necessary to prevent disuse syndrome with muscle atrophy and joint contracture?

Correct Answer: C

Rationale: Approximately 2 hours of activity daily (
C), including range-of-motion exercises or ambulation, helps prevent disuse syndrome, muscle atrophy, and joint contractures in immobilized clients.

Question 4 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. Using the rule of nines, estimate the percentage of body burned.

Correct Answer: B

Rationale: Rule of nines: face/neck (4.5% head anterior), upper half anterior chest (4.5% anterior torso/2 = 2.25%), right arm (9%) = 4.5 + 2.25 + 9 = 23%.

Question 5 of 5

The blood alcohol concentration of a client admitted following a motor vehicle accident is 460 mg/dL. The nurse should give priority to monitoring the client for:

Correct Answer: B

Rationale: A blood alcohol concentration of 460 mg/dL (0.46%) is life-threatening, with respiratory depression being the priority due to its potential to cause death.

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