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Questions 149

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Extract:


Question 1 of 5

The nurse is infusing total parenteral nutrition (TPN). The primary purpose for closely monitoring the client's intake and output is:

Correct Answer: D

Rationale: Monitoring intake and output during TPN helps prevent fluid overload, a risk due to the high volume and osmolarity of the solution.

Question 2 of 5

The obstetric client's fetal heart rate is 80-90 during the contractions. The first action the nurse should take is:

Correct Answer: B

Rationale: A fetal heart rate of 80-90 suggests distress; turning the client to her left side improves uteroplacental perfusion.

Question 3 of 5

The nurse is precepting a student nurse on the medical-surgical unit. The student nurse is preparing to administer insulin. Which action by the student nurse calls for immediate intervention?

Correct Answer: B

Rationale: Regular insulin is the only type safe for IV administration; other insulins like NPH are not, requiring immediate intervention.

Question 4 of 5

The nurse on an orthopedic unit is assigned to care for four clients with displaced bone fractures. Which client will not be treated with the use of traction?

Correct Answer: D

Rationale: Ankle fractures are typically managed with immobilization or surgery, not traction.

Question 5 of 5

The nurse is observing a graduate nurse as she assesses the central venous pressure. Which observation would indicate that the graduate needs further teaching?

Correct Answer: C

Rationale: The Valsalva maneuver falsely elevates CVP; normal breathing is required.

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