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Questions 158

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Question 1 of 5

Which actions should be utilized prior to performing a tub bath on the 80 year-old client?

Correct Answer: B, D

Rationale: For an 80-year-old client, safety and comfort are priorities during a tub bath. A rubber mat (
B) prevents slipping, crucial for elderly clients with reduced mobility. Checking water temperature with a bath thermometer (
D) ensures the water is safe (typically 38-40°C, as 46°C is too hot). Filling the tub half full at 46°C (
A) risks burns, and maintaining water flow pressure (
C) is unnecessary and unsafe. Washing the back (E) and performing a massage (F) occur during or after the bath, not prior.

Question 2 of 5

Which of the following findings would necessitate discontinuing an IV potassium infusion in an adult with ketoacidosis?

Correct Answer: A

Rationale: Adequate renal flow of 30 mL/hr is a necessity with potassium infusions because potassium is excreted renally. Because potassium level will decrease during correction of diabetic ketoacidosis, potassium will be infused even if plasma levels of potassium are normal. A small T wave is normal and desired on the electrocardiogram. A tall, peaked T-wave could indicate overinfusion of potassium and hyperkalemia. Glucose levels of <200 are desirable.

Question 3 of 5

A client with pregnancy-induced hypertension is scheduled for a C-section. Before surgery, the nurse should keep the client:

Correct Answer: C

Rationale: The left lateral position improves uteroplacental blood flow in pregnancy-induced hypertension, reducing fetal distress risk. Right-sided, supine, or knee-chest positions are less optimal.

Question 4 of 5

Diphenoxylate hydrochloride and atropine sulfate (Lomotil) is prescribed for the client with ulcerative colitis. Which of the following nursing observations indicates that the drug is having a therapeutic effect?

Correct Answer: B

Rationale: Lomotil, an antidiarrheal, slows intestinal motility, reducing diarrhea frequency in ulcerative colitis. Decreased diarrhea stools (
B) indicates therapeutic effect. Absent peristalsis (
A), increased cramping (
C), or girth (
D) suggest complications or ineffectiveness.

Question 5 of 5

The nurse is preparing to administer a dose of ondansetron (Zofran) for nausea. Which route is most appropriate for rapid onset?

Correct Answer: C

Rationale: Intravenous ondansetron provides the fastest onset for nausea relief, ideal in acute settings. Oral and sublingual routes are slower, and IM is less common.

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