GCC 126 - 150

A mother of a 3-year-old hospitalized with lead poisoning asks the nurse to explain the treatment for her daughter. The nurse's explanation is based on the knowledge that lead poisoning is treated with:

• Gastric lavage
• Chelating agents
• Antiemetics
• Activated charcoal
• -

Answer explanation

Option 1: Gastric lavage

Option 2: Chelating agents

Option 3: Antiemetics

Option 4: Activated charcoal

Option 5: -

Correct Option: Option 2 – Chelating agents

Explanation: Chelation is standard for heavy metal poisoning.

Objectives for treating diabetic ketoacidosis (DKA) include administering which of the following?

• Glucagon
• Blood products
• Glucocorticoids
• Insulin and I.V. fluids
• -

Answer explanation

Option 1: Glucagon

Option 2: Blood products

Option 3: Glucocorticoids

Option 4: Insulin and I.V. fluids

Option 5: -

Correct Option: Option 4 – Insulin and I.V. fluids

Explanation: Insulin and IV fluids treat hyperglycemia and dehydration in DKA.

A client with diabetes has an order for ultrasonography. Preparation for an ultrasound includes:

• Increasing fluid intake
• Limiting ambulation
• Administering an enema
• Withholding food for 8 hours
• -

Answer explanation

Option 1: Increasing fluid intake

Option 2: Limiting ambulation

Option 3: Administering an enema

Option 4: Withholding food for 8 hours

Option 5: -

Correct Option: Option 1 – Increasing fluid intake

Explanation: Drinking fluids aids in bladder filling for better imaging.

When developing a teaching plan for a client who is 8 weeks pregnant, which of the following foods would the nurse suggest to meet the client's need for increased folic acid?

• Spinach.
• Bananas.
• Seafood.
• Yogurt.
• -

Answer explanation

Option 1: Spinach.

Option 2: Bananas.

Option 3: Seafood.

Option 4: Yogurt.

Option 5: -

Correct Option: Option 1 – Spinach.

Explanation: Green leafy vegetables like spinach are rich in folic acid.

A woman who has delivered a healthy newborn is being discharged. As a part of the discharge teaching, the nurse should instruct the client to observe vaginal discharge for postpartum hemorrhage and notify the healthcare provider about?

• Bleeding that becomes lighter each day
• Clots the size of golf balls
• Saturating a pad in an hour
• Lochia that last longer than 1 week
• -

Answer explanation

Option 1: Bleeding that becomes lighter each day

Option 2: Clots the size of golf balls

Option 3: Saturating a pad in an hour

Option 4: Lochia that last longer than 1 week

Option 5: -

Correct Option: Option 3 – Saturating a pad in an hour

Explanation: Saturation of a pad in an hour may indicate hemorrhage.

A client is admitted to the hospital after being bitten by a bat. Rabies immune globulin, human (BayRab) is ordered as an injection. The drug leaflet instructs to administer 20 IU/kg. This medication comes in vials of 150 IU/mL. The client weighs 220 pounds. How many milliliters should the nurse administer?

• 4.6 mL.
• 9.2 mL.
• 13.3 mL.
• 29.3 mL.
• -

Answer explanation

Option 1: 4.6 mL.

Option 2: 9.2 mL.

Option 3: 13.3 mL.

Option 4: 29.3 mL.

Option 5: -

Correct Option: Option 3 – 13.3 mL.

Explanation: Client weighs 220 lbs = 100 kg. 100 kg × 20 IU = 2000 IU. 2000 ÷ 150 IU/mL = 13.3 mL.

The nurse is discussing pain from cholecystitis with a client. Which statement made by the client most accurately describes the typical pain of this disorder?

• The pain is usually below my sternum.
• Eating food makes the pain better.
• The pain gets worse after I eat fatty foods.
• The pain is usually related to constipation.
• -

Answer explanation

Option 1: The pain is usually below my sternum.

Option 2: Eating food makes the pain better.

Option 3: The pain gets worse after I eat fatty foods.

Option 4: The pain is usually related to constipation.

Option 5: -

Correct Option: Option 3 – The pain gets worse after I eat fatty foods.

Explanation: Gallbladder pain worsens after fatty food intake; typically right upper quadrant or right shoulder.

In planning care for the patient with ulcerative colitis, the nurse identifies which nursing diagnoses as a priority?

• Anxiety
• Impaired skin integrity
• Fluid volume deficit
• Nutrition altered, less than body requirements
• -

Answer explanation

Option 1: Anxiety

Option 2: Impaired skin integrity

Option 3: Fluid volume deficit

Option 4: Nutrition altered, less than body requirements

Option 5: -

Correct Option: Option 3 – Fluid volume deficit

Explanation: Fluid loss can lead to metabolic acidosis and electrolyte imbalance; highest priority.

The nurse is teaching a client with a history of obesity and hypertension regarding dietary requirements during pregnancy. Which statement indicates that the client needs further teaching?

• I need to reduce my daily intake to 1,200 calories a day.
• I need to drink at least a quart of milk a day.
• I shouldn't add salt when I am cooking.
• I need to eat more protein and fiber each day.
• -

Answer explanation

Option 1: I need to reduce my daily intake to 1,200 calories a day.

Option 2: I need to drink at least a quart of milk a day.

Option 3: I shouldn't add salt when I am cooking.

Option 4: I need to eat more protein and fiber each day.

Option 5: -

Correct Option: Option 1 – I need to reduce my daily intake to 1,200 calories a day.

Explanation: 1200 calories is too low for fetal nourishment; reduction shouldn’t be drastic.

A client has just been admitted to the intensive care unit (ICU) and is chemically sedated and paralyzed. What is the best description of the precautions that need to be taken to prevent skin breakdown in this client?

• No precautions are needed. This client is too critically ill to be moved. Keep the client supine to promote circulation to all areas of the body.
• The client needs to be turned at least every 2 hours and should be placed in a 30-degree lateral position if the client becomes too unstable to be turned for more than two hours.
• No precautions are needed. The client is in the ICU and is not at risk for skin breakdown.
• The client needs to be turned at least every 2 hours.
• -

Answer explanation

Option 1: No precautions are needed. This client is too critically ill to be moved. Keep the client supine to promote circulation to all areas of the body.

Option 2: The client needs to be turned at least every 2 hours and should be placed in a 30-degree lateral position if the client becomes too unstable to be turned for more than two hours.

Option 3: No precautions are needed. The client is in the ICU and is not at risk for skin breakdown.

Option 4: The client needs to be turned at least every 2 hours.

Option 5: -

Correct Option: Option 2 – The client needs to be turned at least every 2 hours and should be placed in a 30-degree lateral position if the client becomes too unstable to be turned for more than two hours.

Explanation: Client should be repositioned regularly; 30° lateral helps if too unstable for turning.