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Questions 164

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Question 1 of 5

The nurse is preparing to instill dialysate for a client who is receiving peritoneal dialysis. It would be a priority for the nurse to

Correct Answer: C

Rationale: Sterile technique when spiking and attaching the dialysate bag prevents peritonitis, a life-threatening complication. Semi-Fowler positioning, recording output, and bag placement are important but secondary to infection prevention.

Question 2 of 5

The nurse in a well-child clinic examines many children on a daily basis. Which of the following toddlers requires further follow up?

Correct Answer: D

Rationale: A 30 month-old only drinking from a sippy cup. A 30 month-old should be able to drink from a cup without a cover.

Question 3 of 5

The nurse is planning care for a client who is taking cyclosporin (Neoral). What would be an appropriate nursing diagnosis for this client?

Correct Answer: B

Rationale: Cyclosporin (Neoral) inhibits normal immune responses. Clients receiving cyclosporin are at risk for infection.

Question 4 of 5

The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate?

Correct Answer: C

Rationale: Distended neck veins. Cardiac tamponade causes venous congestion, leading to distended neck veins.

Question 5 of 5

A laboring woman has been pushing for one hour and is not making progress. The nurse knows that which of the following could hinder the descent of the fetus in the second stage of labor?

Correct Answer: A

Rationale: A full bladder obstructs fetal descent by occupying pelvic space, hindering labor progress, unlike anesthesia, positioning, or optimal fetal position.

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