- (Topic 5)
An infant weighing 15 lb has just been treated for severe diarrhea in the hospital. Discharge instructions by the nurse will include maintenance fluid requirements for the pediatric client. Which of the following values best indicates the nurse??s understanding of normal fluid requirements for this infant?
Correct Answer:B
(A, C, D) These answers are incorrect. (B) Normal fluid requirement for this pediatric client is based on the fact that 0–10 kg of weight equals 100 mL/kg per day. This infant weighs 15 pounds (6.8 kg). Thus, 100 mL X 6.8 = 680 mL/day.
- (Topic 6)
A chronic alcoholic client??s condition deteriorates, and he begins to exhibit signs of hepatic coma. Which of the following is an early sign of impending hepatic coma?
Correct Answer:C
(A) Hiccups are not a sign of impending hepatic coma. (B) Anorexia is not a sign of impending hepatic coma. (C) One of the earliest symptoms of hepatic coma is mental confusion. Asterixis, a flapping tremor of the hand, may also be seen. (D) This sign is associated with the later stages of hepatic coma. Fetor hepaticus, a characteristic odor on the breath that smells like acetone, may sometimes be noted when the liver fails.
- (Topic 3)
A client has consented to have a central venous catheter placed. The best position in which to place the client is the Trendelenburg position. The reason is that the Trendelenburg position:
Correct Answer:B
(A) The subclavian vein is not visible during central line insertion regardless of the client??s position. (B) The Trendelenburg position reduces the possibility of air embolism because it places slight positive pressure on the central veins. It also distends the veins, and distention facilitates insertion. (C) This response is untrue; it has no effect on hematoma formation. (D) This position is not necessarily more comfortable for the client, and many clients, especially those who may be short of breath, may find the position uncomfortable and difficult to maintain.
- (Topic 4)
An expected response to sodium polystyrene sulfonate (Kayexalate) is:
Correct Answer:C
(A) Sodium polystyrene sulfonate administration will not increase serum magnesium. Hypermagnesemia is virtually unknown except for clients in renal failure. (B) Sodium polystyrene sulfonate administration is not known to increase serum bicarbonate. (C) Decrease in serum potassium, the expected response of sodium polystyrene sulfonate, is secondary to the binding of this drug and potassium in the colon, and potassium is removed through the feces. (D) Serum calcium may actually increase with sodium polystyrene sulfonate administration, especially if calcium chloride is administered concurrently with this drug.
- (Topic 5)
A male client has a history of diverticulosis. He has questions about the foods that he should eat. His nurse gives him the following information:
Correct Answer:A
(A) Clients with diverticulosis should maintain a high-fiber diet and prevent constipation with bran or bulk laxatives. (B) Lowresidue diets lead to constipation and are contraindicated in clients with diverticulosis. (C) Clients with diverticulosis should drink at least eight glasses of water each day to prevent constipation. (D) Clients with diverticulosis should modify their diet to include high-fiber foods and bulk laxatives.