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Questions 164

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Extract:

Intake and output record
Time Oral intake Parenteral intake Other intake Output
0700 150 mL vancomycin IV
0900 240 mL coffee 1500 mL dialysate
1100 120 mL tea
1300 100 mL cefepime IV 1400 mL dialysate outflow
1500 180 mL juice


Question 1 of 5

The nurse is completing a client's intake and output record for the shift. How many mL should the nurse record as the client's net fluid balance for the shift?

Correct Answer: 890

Rationale: Without specific intake/output data, a general approach is assumed: net fluid balance is calculated as total intake (IV, oral, etc.) minus total output (urine, emesis, etc.). For example, if intake is 2000 mL and output is 1800 mL, the balance is 200 mL. The nurse must sum all recorded values accurately.

Extract:


Question 2 of 5

The nurse assists with a community teaching program for parents and caregivers of infants. Which statement by a participant indicates that teaching has been successful?

Correct Answer: B,D

Rationale: Honey (
A) is unsafe for infants under 1 year due to the risk of botulism. Waiting until 1 year to introduce egg products (
B) is correct to reduce allergy risks. Switching to low-fat milk (
C) is incorrect, as infants need whole milk or formula for adequate fat and nutrients. The ability to pick up finger foods by 12 months (
D) is a correct developmental milestone, indicating successful teaching.

Question 3 of 5

A client returns from the operating room after a right orchiectomy. For the immediate post-operative period the nursing priority would be to

Correct Answer: B

Rationale: Due to the location of the incision, pain management is the priority. Bladder spasms are more related to prostate surgery.

Question 4 of 5

The nurse on the mental health unit is talking with a client with schizophrenia. Which of the following statements by the client would indicate that the client is experiencing a delusion of reference?

Correct Answer: C

Rationale: A delusion of reference involves believing neutral events or objects (e.g., a song on the radio) have personal significance or hidden messages (
C). Auditory hallucinations (
A) involve hearing voices, not reference. Tactile hallucinations (
B) involve false sensations, and persecutory delusions (
D) involve belief in harm without reference to neutral stimuli.

Question 5 of 5

The nurse is caring for a client who is experiencing hypotension and respiratory depression after administration of IV midazolam. The nurse should anticipate that the client will receive

Correct Answer: D

Rationale: Midazolam, a benzodiazepine, can cause respiratory depression and hypotension in overdose. Flumazenil (
D) is the specific antidote, reversing benzodiazepine effects. Acetylcysteine (
A) treats acetaminophen overdose, benztropine (
B) manages extrapyramidal symptoms, and phentolamine (
C) treats hypertensive crises, none of which apply here.

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