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A 3-year-old boy was successfully toilet trained prior to his admission to the
hospital for injuries sustained from a fall. His parents are very concerned that the
child has regressed in his toileting behaviors. Which information should the nurse
provide to the parents?
A. Diapering will be provided since hospitalization is stressful to preschoolers
B. Children usually resume their toileting behaviors when they leave the hospital
C. A potty chair should be brought from home so he can maintain his toileting
skills
D. A retraining program will need to be initiated when the child returns home -
✔✔✔ Correct Answer > B. Children usually resume their toileting behaviors when they
leave the hospital
The nurse is preparing a hepatitis teaching program. Which individual has the
greatest need for teaching about prophylactic hepatitis B immunizations?
A. A child daycare worker who has a history of type 2 diabetes mellitus
B. An ofice worker who requires hemodialysis for chronic kidney disease (CKD)
C. A restaurant chef who was diagnosed one year ago with hepatitis A
,D. A sales person who travels internationally and eats food in foreign countries. -
✔✔✔ Correct Answer> B. An ofice worker who requires hemodialysis for chronic kidney
disease (CKD)
During discharge teaching, an overweight client with heart failure (HF) is asked to
make a grocery list for the nurse to review. Which food choices included on the
client's list should the nurse encourage?
A. Canned fruit in heavy syrup
B. Natural whole almonds
C. Plain, air-popped popcorn
D. Lightly salted potato chips
E. Cheddar cheese cubes - ✔✔✔ Correct Answer>B. Natural whole almonds
C. Plain, air-popped popcorn
The charge nurse of a critical care unit is informed at the beginning of the shift
that less than the optimal number of registered nurses will be working that shift.
In planning assignments, which client should receive the most care hours by a
registered nurse (RN)?
A. A 48-year-old marathon runner with a central venous catheter who is
experiencing nausea and vomiting due to electrolyte disturbance following a race
B. A 34-year-old admitted today after an emergency appendectomy who has a
peripheral intravenous catheter and a Foley catheter
C. A 63-year-old chain smoker admitted with chronic bronchitis who is receiving
oxygen via nasal cannula and has a saline-locked peripheral intravenous catheter
D. An 82-year-old client with Alzheimer's disease and a newly-fractured femur
who has a Foley catheter and soft wrist restraints applied - ✔✔✔ Correct Answer>D. An
,82-year-old client with Alzheimer's disease and a newly-fractured femur who has a
Foley catheter and soft wrist restraints applied
A male client with stomach cancer returns to the unit following a total gastrectomy.
He has a nasogastric tube to suction and is receiving Lactated Ringer's solution at
75 mL/hr IV. One hour after admission to the unit, the nurse notes 300mL of blood
in the suction canister, the client's heart rate is 155 beats/minute, and his blood
pressure is 78/48 mmHg. In addition to reporting the findings to the surgeon,
which action should the nurse implement first?
A. Measure and document the client's urinary output
B. Request the client's reserved unit of packed red blood cells
C. Prepare for placement of a central venous catheter
D. Increase the infusion rate of Lactated Ringer's solution - ✔✔✔ Correct Answer>D.
Increase the infusion rate of Lactated Ringer's solution
A heparin infusion is prescribed for a client who weighs 220 pounds. After
administering a bolus dose of 80 units/kg, the nurse calculates the infusion rate for
the heparin solution as 18 units/kg/hour. The available solution is Heparin Sodium
25,000 Units in 5% Dextrose Injection 250 mL. The nurse should program the
infusion pump to deliver how many mL/hour? - ✔✔✔ Correct Answer>-1st: calculate the
weight = 220/2.2= 100kg
-Then calculate total dose in units = 18units x 100kg = 1800 units/hr
- 25000 units - in 250
1800 units ---in X ml
x = 1800 x 250/25000 =18 mL/hr
, An adult male who fell 20 feet from the roof of his home has multiple injuries,
including a right pneumothorax. Chest tubes were inserted in the emergency
department prior to his transfer to the intensive care unit (ICU). The nurse notes
that the suction control chamber is bubbling at the -10cm H2O mark, which
fluctuation in the water seal, and over the past hour 75 mL of bright red blood is
measured in the collection chamber. Which intervention should the nurse
implement?
A. Add sterile water to the suction control chamber
B. Give blood from the collection chamber as autotransfusion
C. Manipulate blood in tubing to drain into chamber
D. Increase wall suction to eliminate fluctuation in water seal - ✔✔✔ Correct Answer>A.
Add sterile water to the suction control chamber
An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife
approaches the nurse and asks how she will know that her husband's death is
imminent because their two adult children want to be there when he dies. Which is
the best response by the nurse?
A. Gather information regarding how long it will take for the children to arrive
B. Explain that the client will start to lose consciousness and the body systems will
slow down
C. Reassure the spouse that the healthcare provider will notify when to call the
children
D. Offer to discuss the client's health status with each of the adult children - ✔✔✔
Correct Answer > B. Explain that the client will start to lose consciousness and the body
systems will slow down