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Questions 227

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Extract:


Question 1 of 5

While assessing an Rh positive newborn whose mother is Rh negative, the nurse recognizes the risk for hyperbilirubinemia. Which of the following should be reported immediately?

Correct Answer: C

Rationale: The elevated bilirubin is in the range that requires immediate intervention, such as phototherapy. At a serum bilirubin of 12 mg, the neonate is at risk for the development of kernicterus, or bilirubin encephalopathy. The provider determines the therapy appropriate after reviewing all laboratory findings.

Question 2 of 5

The physician has prescribed Cytoxan (cyclophosphamide) for a client with nephrotic syndrome. The nurse should:

Correct Answer: A

Rationale: Cyclophosphamide is nephrotoxic; extra fluids promote excretion and reduce bladder toxicity. Low-protein diets are not indicated, mild soap is unrelated, and joints are not typically inflamed in nephrotic syndrome.

Extract:

The physician orders high protein, high calorie and high salt diet on Valerie.


Question 3 of 5

When ask by the patient, the nurse would explain that

Correct Answer: D

Rationale: Lack of mineralcorticoids (aldosterone) leads to a loss of sodium ions in the urine and subsequent hyponatremia, necessitating a high salt diet.

Extract:

Marie is a 38-year-old primigravida who is admitted with a diagnosis of pregnancy induced hypertension (PIH).


Question 4 of 5

Priority nursing care on the patient with PIH include:

Correct Answer: C

Rationale: Low urine output (335 ml/24 hours) indicates possible renal involvement in PIH, a priority for monitoring and reporting to prevent further complications.

Extract:


Question 5 of 5

Dual diagnosis indicates that there is a substance abuse problem as well as a

Correct Answer: B

Rationale: Dual diagnosis is the concurrent presence of a major psychiatric disorder and chemical dependence.

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