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Questions 158

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Extract:


Question 1 of 5

The nurse notes hyperventilation in a client with a thermal injury. She recognizes that this may be a reaction to which of the following medications if applied in large amounts?

Correct Answer: B

Rationale: Mafenide acetate can cause metabolic acidosis, leading to compensatory hyperventilation. The other medications listed do not typically cause this reaction.

Question 2 of 5

A client is admitted to the labor room. She is dilated 4 cm. She is placed on electric fetal monitoring. Which of the following observations necessitates notifying the physician?

Correct Answer: A

Rationale: These are tetanic in nature and can cause rupture of the uterus. The FHR decreases during contractions owing to vasoconstriction and should recover after the contraction. Beat-to-beat variability is a normal finding and demonstrates fetal well-being. The FHR may decrease at the beginning of a contraction owing to head compression.

Question 3 of 5

The nurse caring for a client in shock recognizes that the glomerular filtration rate of the kidneys will fail if the client's mean arterial pressure falls below which of the following levels?

Correct Answer: D

Rationale: A mean arterial pressure (MAP) below 80 mmHg compromises renal perfusion, leading to glomerular filtration failure. Higher MAPs (A, B,
C) maintain adequate kidney function.

Question 4 of 5

The nurse is assessing a trauma client in the emergency room when she notes a penetrating abdominal wound with exposed viscera. The nurse should:

Correct Answer: B

Rationale: Exposed viscera should be covered with sterile saline-soaked gauze to keep them moist and prevent infection until surgical repair. Replacing contents or using non-sterile/petroleum dressings is unsafe.

Question 5 of 5

A client has had a unilateral adrenalectomy to remove a tumor. The most important measurement in the immediate post-operative period for the nurse to take is:

Correct Answer: A

Rationale: Adrenalectomy can disrupt cortisol and aldosterone production leading to blood pressure instability (e.g. hypotension from adrenal insufficiency). Monitoring blood pressure is critical to detect and manage these changes promptly.

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