Nokea
Which of the following indicates that a 5-month-old weighing 15 lb and being treated for dehydration has a normal urine output? The urine output is:
- A. 1 to 2 mL/kg/hour.
- B. 3 to 5 mL/kg/hour.
- C. 6 to 8 mL/kg/hour.
- D. 10 to 12 mL/kg/hour.
Correct Answer: A
Rationale: Normal urine output for an infant is 1 to 2 mL/kg/hour, indicating adequate hydration. Higher outputs may suggest overhydration or other issues.
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A client with a spinal cord injury is at risk for autonomic dysreflexia. Which symptom should the nurse monitor for?
- A. Bradycardia.
- B. Hypotension.
- C. Severe headache.
- D. Increased urine output.
Correct Answer: C
Rationale: Severe headache is a key sign of autonomic dysreflexia, often triggered by bladder or bowel issues.
The nurse is preparing to administer a dose of warfarin (Coumadin) to a client. The client's International Normalized Ratio (INR) is 4.0. What should the nurse do?
- A. Administer the dose as ordered.
- B. Hold the dose and notify the physician.
- C. Administer half the prescribed dose.
- D. Administer vitamin K as an antidote.
Correct Answer: B
Rationale: An INR of 4.0 is above the therapeutic range (2-3), indicating a risk of bleeding, so the nurse should hold the dose and notify the physician.
The nurse is caring for a client with a history of burns. Which of the following complications should the nurse monitor for in the acute phase?
- A. Hypovolemia.
- B. Hypernatremia.
- C. Hypoglycemia.
- D. Respiratory alkalosis.
Correct Answer: A
Rationale: Hypovolemia is a major complication in the acute phase of burns due to fluid loss.
The nurse is teaching an unlicensed assistive personnel about the care of clients with self-mutilation. Which of the following, if stated by the unlicensed personnel about self-mutilation, demonstrates that the teaching has been effective?
- A. It is a means of getting what the person wants.'
- B. It is a nonserious event that can be ignored.'
- C. It is a way to express anger and rage.'
- D. It is a form of manipulation.'
Correct Answer: C
Rationale: Self-mutilation is often a way to express intense emotions like anger or rage, indicating the assistant understands its emotional significance.
When developing the plan of care for a 12-year-old child who is to receive 48 hours of chemotherapy that is associated with nausea and vomiting, at which of the following times should the nurse anticipate administering an antiemetic?
- A. Immediately following chemotherapy.
- B. 30 minutes before the chemotherapy starts, then every 4 to 6 hours.
- C. When the 12-year-old requests medication for nausea, then every 4 hours as needed.
- D. On starting the chemotherapy infusion, and then routinely every 8 hours.
Correct Answer: B
Rationale: Administering an antiemetic 30 minutes before chemotherapy and every 4-6 hours prophylactically minimizes nausea and vomiting.