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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 client with a pacemaker should be taught to:

Correct Answer: D

Rationale: Monitoring pulse rate ensures the pacemaker is functioning correctly and detects arrhythmias.

Question 3 of 5

The nurse has just administered morphine 4 mg IV to a client with severe pain from a kidney stone. The client then asks to get up to the toilet. Which is the correct nursing action for this client?

Correct Answer: B

Rationale: Morphine can cause sedation and dizziness, increasing fall risk. Offering a bedpan or urinal is safer than ambulating to the toilet.

Question 4 of 5

The nurse is developing a plan for bowel and bladder retraining for a client with paraplegia. The primary goal of a bowel and bladder retraining program is:

Correct Answer: C

Rationale: The primary goal is to prevent complications like infections or skin breakdown by establishing effective bowel and bladder management.

Question 5 of 5

The nurse is caring for a client with a head injury who has an intracranial pressure monitor in place. Assessment reveals an ICP reading of 66. What is the nurse's best action?

Correct Answer: A

Rationale: An ICP of 66 mmHg is critically high (normal <20 mmHg), indicating severe brain swelling. Notifying the physician is urgent for immediate intervention.

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