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Questions 158

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Question 1 of 5

Which of the following blood values would require further nursing action in a newborn who is 4 hours old?

Correct Answer: C

Rationale: A serum glucose of 30 mg/dL in the first 72 hours of life is indicative of hypoglycemia and warrants further intervention.

Question 2 of 5

Seven days ago, a 45-year-old female client had an ileostomy. She is self-sufficient and well otherwise. Which of the following long-term objectives would be unrealistic?

Correct Answer: A

Rationale: Because of the location of an ileostomy, the client will not be able to control the evacuation of her bowels. The ileostomy will drain liquid stool continuously. The client should be able to return to a normal, well-balanced diet. She should avoid foods that cause diarrhea or excessive gas production, and she should eat small meals. The client should be able to resume sexual activity. She will be able to wear a pouch. The client has no other health or mental problems and should be able to manage her own ileostomy.

Question 3 of 5

A client with hypothyroidism frequently complains of feeling cold. The nurse should tell the client that she will be more comfortable if she:

Correct Answer: B

Rationale: Dressing in extra layers is a safe, effective way to manage cold intolerance in hypothyroidism by conserving body heat. Electric blankets and heating pads pose burn risks, and baths are temporary.

Question 4 of 5

The client is admitted with a diagnosis of bacterial meningitis. Which precaution should the nurse implement?

Correct Answer: B

Rationale: Bacterial meningitis (e.g., Neisseria meningitidis) is transmitted via respiratory droplets, requiring droplet precautions. Standard, contact, and airborne precautions are not appropriate.

Question 5 of 5

Which clients can be assigned to share a room in the emergency department during a disaster?

Correct Answer: B

Rationale: A pregnant client and a client with a fractured arm have stable non-infectious conditions suitable for sharing a room. The other pairs include clients with unstable (cyanosis abdominal wound chest pain) or infectious (MRS
A) conditions or psychiatric issues requiring isolation.

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