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Questions 158

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Extract:


Question 1 of 5

Which one of the following is considered a reliable indicator for assessing the adequacy of fluid resuscitation in a 3-year-old child who suffered partial- and full-thickness burns to 25% of her body?

Correct Answer: A

Rationale: Urinary output is a reliable indicator of renal perfusion, which in turn indicates that fluid resuscitation is adequate. IV fluids are adjusted based on the urinary output of the child during fluid resuscitation. Edema is an indication of increased capillary permeability following a burn injury. Hypertension is an indicator of fluid volume excess. Fontanelles close by 18 months of age.

Question 2 of 5

A client confides to the nurse that he tasted poison in his evening meal. This would be an example of what type of hallucination?

Correct Answer: B

Rationale: Auditory hallucinations involve sensory perceptions of hearing. Gustatory hallucinations involve sensory perceptions of taste. Olfactory hallucinations involve sensory perceptions of smell. Visceral hallucinations involve sensory perceptions of sensation.

Question 3 of 5

The home care nurse is preparing a teaching plan for a client with deficiencies in folic acid. Which foods will increase the clients' folic acid level?

Question Image

Correct Answer: A, B, D

Rationale: Folic acid-rich foods include broccoli (
A), cabbage (
B), and dried fruit (
D). Chicken (
C), white bread (E), and milk (F) are low in folate.

Question 4 of 5

The nurse is caring for a client with a history of peripheral artery disease. The nurse should expect the client to have:

Correct Answer: A

Rationale: Peripheral artery disease reduces blood flow, causing intermittent claudication (leg pain with activity) due to muscle ischemia.

Question 5 of 5

The nurse is removing a peripherally inserted central catheter (PICC). The nurse should position the patient in which position?

Correct Answer: D

Rationale: Trendelenburg position (head down) is used when removing a PICC line to reduce the risk of air embolism by increasing venous pressure. Fowler’s, right, or left side-lying positions do not provide this protection.

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