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Questions 149

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Question 1 of 5

To maintain Bryant's traction, the nurse must make certain that the child's:

Correct Answer: B

Rationale: Bryant's traction requires hips slightly elevated and legs at a right angle to the bed to maintain alignment and traction.

Question 2 of 5

One week after discharge of a postpartum client, the client's husband calls the postpartum unit and asks the nurse, 'Is it normal for my wife to cry at the drop of a hat? I'm worried I've done something to upset her.' The nurse's best initial response would be:

Correct Answer: B

Rationale: Postpartum blues are common within the first two weeks, characterized by emotional lability. Reassuring the husband while acknowledging the normalcy of this condition is appropriate.

Question 3 of 5

The nurse is caring for an organ donor client with a severe head injury from an MVA. Which of the following is most important when caring for the organ donor client?

Correct Answer: A

Rationale: Maintaining BP at 90 mmHg or greater ensures organ perfusion, critical for organ viability in a donor. Normal temperature and adequate urine output are important, but BP is the priority. Low hematocrit is not a goal.

Question 4 of 5

The nurse is assisting a client with a colostomy irrigation. The client is positioned on the toilet and has removed the colostomy pouch, and the irrigation bag is filled with 1000 mL of warm water. Place the following actions (in Roman numerals) in the correct order from first to last

Order the Items

Source Container

Allow 15 to 20 minutes for evacuation and then fold the sleeve, secure it, and leave it in place for 30 to 45 minutes before removing it.
Allow the solution to flow in for 5 to 10 minutes and then clamp the tubing and close the top of the irrigation sleeve.
Apply gloves, lubricate the cone tip, and insert it into the stoma, holding it securely.
Apply the irrigation sleeve over the stoma.
Hang the irrigation solution with the bottom of the bag being 20 inches above the stoma.

Correct Answer: E,D,C,B,A

Rationale: The correct order is: Hang the irrigation solution (V), apply the irrigation sleeve (IV), insert the cone tip (III), allow solution to flow (II), and allow evacuation (I), ensuring proper setup and procedure.

Question 5 of 5

A newborn weighed 7 pounds at birth. At 6 months of age, the infant could be expected to weigh:

Correct Answer: A

Rationale: Infants typically double their birth weight by 6 months, so a 7-pound newborn would weigh approximately 14 pounds.

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