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Questions 149

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Question 1 of 5

The physician has ordered intravenous fluid with potassium for a client admitted with gastroenteritis and dehydration. Before adding potassium to the intravenous fluid, the nurse should:

Correct Answer: A

Rationale: Adequate urinary output (at least 30 mL/hr) must be confirmed before adding potassium to IV fluids to prevent hyperkalemia.

Question 2 of 5

A 34-year-old client is receiving an IM injection of ceftriaxone (Rocephin) for a urinary tract infection. Which is correct regarding IM injections?

Correct Answer: C

Rationale: IM injections are given at a 90-degree angle to ensure muscle penetration. A 25-gauge needle is too small, a 45-degree angle is for subcutaneous injections, and a bleb indicates intradermal injection.

Question 3 of 5

The nurse is caring for a client with acquired immunodeficiency syndrome who has oral candidiasis. The nurse should clean the client's mouth using:

Correct Answer: B

Rationale: A soft gauze pad is gentle and effective for cleaning the mouth in oral candidiasis without causing trauma.

Question 4 of 5

Which would be included in the nursing care plan of a client experiencing severe delirium tremens?

Correct Answer: B

Rationale: Keeping closet and bathroom doors closed minimizes visual stimuli that could exacerbate hallucinations or confusion in delirium tremens, promoting a safe environment.

Question 5 of 5

A client in restraints is assigned to a newly graduated nurse. The nurse understands that which of the following are true regarding restraints? Select all that apply.

Correct Answer: A, C, F

Rationale: Restraints include chemical, mechanical, or physical methods; bed rails are restraints if used to restrict movement; and non-restraint alternatives like active listening are preferred. Pediatric time limits and reassessment frequency vary by policy, and reapplication requires new orders.

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