Nokea
Which of the following is the most accurate method of determining the extent of a client's fluid loss?
- A. Measuring intake and output
- B. Assessing vital signs
- C. Weighing the client
- D. Assessing skin turgor
Correct Answer: C
Rationale: Daily weighing is the most accurate method to assess fluid loss, as 1 kg of weight loss corresponds to 1 liter of fluid loss. Intake/output, vital signs, and skin turgor are less precise.
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You routinely use the PQRST method to assess pain. The PQRST method consists of:
- A. Pain level, the quality of the pain, the region or area of the pain, the severity of the pain, and the pain triggers
- B. Precipitating factors, the quality of the pain, relief factors, the severity of the pain, and the pain triggers
- C. Pain level, the quantitative numerical pain score, the region or area of the pain, the severity of the pain, and the pain triggers
- D. Precipitating factors, the quality of the pain, the region or area of the pain, the severity of the pain, and the pain triggers
Correct Answer: D
Rationale: The PQRST method assesses pain through Precipitating factors, Quality, Region, Severity, and Timing (triggers).
You are going to perform gastric lavage for your adult client who was accidentally poisoned. How many mLs of irrigating solution would you instill after each suctioning?
- A. 100 mLs
- B. 250 mLs
- C. 400 mLs
- D. 500 mLs
Correct Answer: B
Rationale: Gastric lavage typically involves instilling 200-300 mL of solution (commonly 250 mL) per cycle to effectively wash out the stomach contents.
The charge nurse on the postpartum unit has received report about a client with a fetal demise who has just delivered and will be ready for transfer out of Labor and Delivery in about 2 hours. The client has asked her primary nurse if she can stay on the unit since she found support from the nursing staff there. What action should the charge nurse on the postpartum unit take?
- A. Request a room for this client on a unit without newborns.
- B. Ask the nurse in labor and delivery to discharge the mother as soon as she is physically able to leave.
- C. Talk to the mother first and decide on a location that is mutually agreeable.
- D. Admit the mother to a private room on the postpartum unit.
Correct Answer: A
Rationale: Placing the client on a unit without newborns minimizes emotional distress from being near other newborns after a fetal demise.
The administration of an intramuscular injection to a neonate should be given in the:
- A. Gluteus maximus muscle.
- B. Vastus lateralis muscle.
- C. Deltoid muscle.
- D. The sternocleidomastoid muscle.
Correct Answer: B
Rationale: The vastus lateralis is the preferred site for IM injections in neonates due to its large muscle mass and minimal risk of nerve or bone injury.
The nurse is providing medication instructions to a client who is prescribed imipramine daily. Which statement by the client indicates a need for further teaching?
- A. I need to avoid alcohol while taking the medication.
- B. I need to take the medication in the morning before breakfast.
- C. The effects of the medication may not be noticed for at least 2 weeks.
- D. A missed dose should be taken as soon as possible unless it is almost time for the next dose.
Correct Answer: B
Rationale: Imipramine is a tricyclic antidepressant (TCA). The client should be instructed to take the medication (a single dose) at bedtime and not in the morning because it causes fatigue and drowsiness. The client is told to avoid alcohol or other central nervous system depressants during therapy and that medication effects may not be noticed for at least 2 weeks. The client is instructed to take the medication exactly as directed, and if a dose is missed, to take it as soon as possible unless it is almost time for the next dose.