Correct Answer: C

(A) The combination of sugar and juice will increase the blood sugar beyond the normal range. (B) Concentrated sweets are not absorbed as fast as juice; consequently, they elevate the blood sugar beyond the normal limit. (C) Four ounces of orange juice will act immediately to raise the blood sugar to a normal level and sustain it for 30 minutes until supper is served. (D) There is an increased potential for the client's blood sugar to decrease even further, resulting in diabetic coma.

Correct Answer: D

(A) A gavage tube may damage suture line. It is the most invasive and should be the last measure. (B) A nipple and bottle require sucking, which may damage sutures. (C) A 3- month-old infant is not able to drink from a straw. (D) A syringe allows for the formula to be placed to the side and back of the mouth. This minimizes the amount of sucking needed.

Correct Answer: D

(A) Clients in renal failure typically have very low hematocrits, often in the range of 16?2%. (B) Transfusion is avoided unless the client exhibits acute symptoms such as dyspnea, chest pain, tachycardia, and extreme fatigue. When the client is given a transfusion, the bone marrow adjusts by producing less red blood cells. (C) Anemia in renal failure is caused primarily by decreased erythropoietin. Low serum iron and ferritin may aggravate the anemia and require treatment. (D) Decreased secretion of erythropoietin by the kidney is the primary cause of anemia. The bone marrow requires this hormone to mature red blood cells. Treatment is with replacement therapy.

Correct Answer: A

The nurse appropriately states how he or she feels when the client speaks in a condescending manner. (B) This statement indicates that the client has control over the nurse. No one makes another person angry; each individual has a choice.

(C) "Why" questions usually put a person on the defensive. In addition, the client cannot "make" the nurse angry. The client does not have that control. (D) Again, a "why" statement places the client on the defensive.

Correct Answer: C

(A) Zinc oxide is not usually applied to inflamed areas because it contributes to sweat retention. (B) Talcum powder is of questionable benefit and poses a hazard of accidental inhalation. (C) Removing the diaper and exposing the area to air and light facilitate drying and healing. (D) Infants may be sensitive to one or more agents in the wet "wipes." It is better to simply clean with a wet cloth.

Correct Answer: D

(A) This response does not show any insight; the client falsely assumes that she is responsible for the rape. (B) The client continues to falsely assume responsibility for the rapist's behavior. (C) The client believes falsely that rape is an act of passion, rather than one of violence, control, and domination. (D) The client has insight into the rape; she does not believe it was her fault and shows good judgment in deciding to continue with counseling after discharge.

Correct Answer: B

(A) Blood pressure can remain normotensive in a state of hypovolemia. (B) Capillary refill, alterations in sensorium, and urine output are the most reliable indicators for assessing hydration. (C) Skin turgor is not a reliable indicator for assessing hydration in a burn client. (D) Fluid intake does not indicate adequacy of fluid resuscitation in a burn client.

Correct Answer: B

(A) There are no indications that the client's thoughts reflect special powers or talents characteristic of grandiosity. (B) The client's thought content is fixed, false, persecutory, and suspicious in nature, which is characteristic of paranoid delusions. (C, D) The client is not demonstrating a sensory experience.

Correct Answer: A

(A) Thrombocytopenia, a decrease in platelets, occurs in lupus and causes a decrease in blood coagulation and thrombus formation. (B) Clients with lupus will have a decrease in the WBC count decreasing their resistance to infection. (C) Clients with lupus may have a decrease in the hemoglobin level causing anemia. (D) Leukopenia, a decrease in white blood cells, is seen in lupus and decreases resistance to infection.

Correct Answer: A

(A) Adequate renal flow of 30 mL/hr is a necessity with potassium infusions because potassium is excreted renally. (B) Because potassium level will decrease during correction of diabetic ketoacidosis, potassium will be infused even if plasma levels of potassium are normal. (C) A small T wave is normal and desired on the electrocardiogram. A tall, peaked T-wave could indicate overinfusion of potassium and hyperkalemia. (D) Glucose levels of <200 are desirable.