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Questions 158

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Question 1 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 2 of 5

A mother calls the clinic to report that her otherwise healthy newborn has a rash on his forehead and face. The nurse should tell the mother:

Correct Answer: B

Rationale: Many newborns develop erythema toxicum or milia benign rashes that resolve within a month. This is the most likely explanation for a healthy newborn’s facial rash. Immediate evaluation or family illness checks are unnecessary unless other symptoms are present.

Question 3 of 5

A client with a fractured femur is placed in skeletal traction. Which assessment finding requires immediate intervention?

Correct Answer: A

Rationale: A cool foot indicates potential vascular compromise, a serious complication in skeletal traction requiring immediate intervention to prevent tissue damage. Pain is expected, weights on the floor disrupt traction but are less urgent, and exercises are encouraged if appropriate.

Question 4 of 5

The nurse is interviewing a client with a diagnosis of possible abdominal aortic aneurysm. Which of the following statements will be reflected in the client's chief complaint?

Correct Answer: D

Rationale: (A, B,
C) These complaints are not specific signs and symptoms associated with abdominal aortic aneurysm. If symptoms are present, the aneurysm is expanding or rupture is imminent. Many clients may experience no symptoms. The only symptom may be a pulsation noted in the abdomen in the reclining position.

Question 5 of 5

The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:

Correct Answer: C

Rationale: Epidural anesthesia can diminish bladder sensation leading to urinary retention. Hourly catheterization prevents bladder distention and complications. The other reasons are not accurate or relevant to epidural effects.

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