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Questions 164

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Extract:


Question 1 of 5

The nurse is reinforcing teaching about constipation prevention to a client. Which of the following client statements indicate appropriate understanding of the teaching? Select all that apply.

Correct Answer: B,D,E

Rationale: A routine, high-fiber diet, and exercise prevent constipation. Caffeine can dehydrate, and frequent laxative use is not recommended.

Question 2 of 5

Triazolam (Halcion) 0.25 mg is ordered for a client at bedtime. When the nurse goes to give the medication, the client asks the nurse to leave it at the bedside because she wants to finish reading a book. What is the best action for the nurse to take?

Correct Answer: B

Rationale: Returning in an hour ensures medication administration while respecting the client's request, adhering to safety protocols. Leaving medication or delaying indefinitely risks errors.

Extract:

Intake and output record

Emesis 120 mL
Wet diaper 1 50 g
Wet diaper 2 52 g
Wet diaper 3 46 g

*Weight of a dry diaper = 30 g
Intake and output record


Question 3 of 5

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

Correct Answer: 208

Rationale: Emesis (120 mL) plus diaper output (50-30=20 mL, 52-30=22 mL, 46-30=16 mL) totals 120+20+22+16=208 mL.

Extract:


Question 4 of 5

The parents of an adolescent who is being treated for a serious head injury ask why their child is being kept unconscious. The parents say, 'The doctor said he was going to give him medicine to keep him unconscious for a few days. Why? We want to talk to him. What is going on?' What should the nurse include when responding to the parents?

Correct Answer: B

Rationale: Barbiturates induce coma in severe head injuries to reduce cerebral metabolism and intracranial pressure, protecting the brain, unlike pain control or restlessness management.

Question 5 of 5

The health care provider has prescribed spironolactone to be given in addition to hydrochlorothiazide to a client with hypertension. Which finding by the nurse indicates that the spironolactone is having the desired effect?

Correct Answer: B

Rationale: Spironolactone is a potassium-sparing diuretic, so a normal potassium level indicates it is counteracting the potassium loss from hydrochlorothiazide.

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