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Questions 163

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Question 1 of 5

Which client event would be considered an adverse event and would require completion of an incident/event/irregular occurrence/variance report? Select all that apply.

Correct Answer: B,D,E

Rationale: Adverse events requiring an incident report include worsening cellulitis due to missed antibiotics , a fall even without injury , and a significant delay in a STAT procedure . Late medication administration is a variance but not typically an adverse event unless harm occurs, and a seizure in a known epileptic is expected unless protocol was not followed.

Question 2 of 5

In the intensive care unit, the nurse cares for a client admitted with a head injury who develops syndrome of inappropriate antidiuretic hormone. Which data should the nurse expect with the onset of this condition? Select all that apply.

Correct Answer: A,C,E

Rationale: SIADH causes water retention, leading to decreased serum osmolality , high urine specific gravity , and low serum sodium due to dilution. High osmolality and increased urine output are opposite findings.

Question 3 of 5

The nurse is assessing a newborn delivered at home by a client addicted to heroin. Which of the following would the nurse expect to observe?

Correct Answer: D

Rationale: Jitteriness at 24-48 hours. Withdrawal signs may not be evident for 1-2 days after birth. Irritability and poor feeding also are evident.

Question 4 of 5

The nurse prepares equipment for insertion of a large bore nasogastric (NG) tube for a hospitalized client. Which actions should the nurse take to measure and mark the tube? Select all that apply.

Correct Answer: C,D

Rationale:
To measure an NG tube, measure from nose to earlobe to xiphoid process for approximate insertion depth and mark with tape . Folding in half is inaccurate, measuring to stomach is vague, and rubber clamps are not standard.

Question 5 of 5

The nurse is talking with a client who has a new prescription for metronidazole. Which of the following statements by the client would require follow up?

Correct Answer: A

Rationale: Drinking alcohol while taking metronidazole can cause a disulfiram-like reaction, requiring follow-up. Metallic taste and dark urine are common side effects, and reporting rash or peeling is appropriate.

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