Nokea
The doctor has ordered a restricted fluid intake for a 2-year-old child with a head injury. Normal fluid intake for a child of 2 years is:
- A. 900 mL/24 hr
- B. 1300 mL/24 hr
- C. 1600 mL/24 hr
- D. 2000 mL/24 hr
Correct Answer: C
Rationale: Normal intake for a child of 2 years is about 1600 mL in 24 hours.
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A client with a right lobectomy is being transported from the intensive care unit to a medical unit. The nurse understands that the client's chest drainage system:
- A. Can be disconnected from suction if the chest tube is clamped
- B. Can be disconnected from suction, but the chest tube should remain unclamped
- C. Must remain connected by means of a portable suction
- D. Must be kept even with the client's shoulders during the transport
Correct Answer: B
Rationale: The chest drainage system can be disconnected from suction during transport, but the tube must remain unclamped to allow air or fluid to escape, preventing pneumothorax. Portable suction is not always needed.
The nurse is teaching a client with a history of chronic kidney disease about dietary modifications. The nurse should tell the client to:
- A. Limit phosphorus intake
- B. Increase sodium intake
- C. Consume high-potassium foods
- D. Increase protein intake
Correct Answer: A
Rationale: Limiting phosphorus intake prevents bone and cardiovascular complications in chronic kidney disease.
The client has been in active labor for the last 12 hours. During the last 3 hours, labor has been augmented with oxytocin because of hypoactive uterine contractions. Her physician assesses her cervix as 95% effaced, 8 cm dilated, and the fetus is at 0 station. Her oral temperature is 100.2F at this time. The physician orders that she be prepared for a cesarean delivery. In preparing the client for the cesarean delivery, which one of the following physician's orders should the RN question?
- A. Administer meperidine (Demerol) 100 mg IM 1 hour prior to the delivery.
- B. Discontinue the oxytocin infusion.
- C. Insert an indwelling Foley catheter prior to delivery.
- D. Prepare abdominal area from below the nipples to below the symphysis pubis area.
Correct Answer: A
Rationale: Meperidine crosses the placental barrier and can cause respiratory depression in the fetus, making it inappropriate for preoperative cesarean delivery.
The nurse is reviewing the results of a sweat test taken from a child with cystic fibrosis. Which finding supports the client's diagnosis?
- A. A sweat potassium concentration less than 40 mEq/L
- B. A sweat chloride concentration greater than 60 mEq/L
- C. A sweat potassium concentration greater than 40 mEq/L
- D. A sweat chloride concentration less than 40 mEq/L
Correct Answer: B
Rationale: A sweat chloride concentration >60 mEq/L is diagnostic for cystic fibrosis due to defective chloride channels. Potassium levels are not diagnostic, and low chloride is normal.
The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?
- A. The client with Cushing's disease
- B. The client with diabetes
- C. The client with acromegaly
- D. The client with myxedema
Correct Answer: A
Rationale: The client with Cushing’s disease may have immune suppression due to excess cortisol, increasing infection risk. A private room minimizes exposure to pathogens. Diabetes, acromegaly, and myxedema do not typically require isolation.