Nokea
Assessment findings of a 3-hour-old newborn include: axillary temperature of 97.7°F, heart rate of 140 beats/minute with a soft murmur, and irregular respiratory rate at 42 breaths/min. Based on these findings, what action should the nurse implement?
- A. Place a pulse oximeter on the heel
- B. Swaddle the infant in a warm blanket
- C. Record the findings on the flow sheet
- D. Check the vital signs in 15 minutes
Correct Answer: C
Rationale: The correct action for the nurse to take in this scenario is to record the findings on the flow sheet. The newborn's axillary temperature, heart rate, and respiratory rate are within normal limits for a 3-hour-old newborn. Therefore, there is no immediate need for intervention or further assessment. Swaddling the infant in a warm blanket, placing a pulse oximeter on the heel, or checking the vital signs in 15 minutes are not necessary actions based on the normal assessment findings presented. These actions could potentially disrupt the newborn or lead to unnecessary interventions when the baby is stable.
You may also like to solve these questions
Several clients on a busy antepartum unit are scheduled for procedures that require informed consent. Which situation should the nurse explore further before witnessing the client's signature on the consent form?
- A. The client was medicated for pain with a narcotic analgesic IM 6 hours ago
- B. A 15-year-old primigravida who has been self-supporting for the past 6 months
- C. The obstetrician explained a procedure that a neurologist will perform
- D. The client is illiterate but verbalizes understanding and consent for the procedure
Correct Answer: D
Rationale: The correct answer is D because an illiterate client may require additional support to ensure they fully comprehend the information provided in the informed consent process. It is crucial to confirm that the client truly understands the nature of the procedure, its risks, and benefits. While it is important to assess pain control (choice A), a client's previous medication administration does not directly impact their ability to understand the consent process. Choice B, a 15-year-old primigravida who has been self-supporting, may legally provide informed consent depending on the jurisdiction and circumstances, so this situation may not require further exploration. Choice C, explaining a procedure by a different specialist, does not necessarily require additional exploration before witnessing the client's consent.
A client complains of paresthesia in the fingers and toes and experiences hand spasms when the blood pressure cuff is inflated. Which serum laboratory finding should the nurse expect to find when assessing the client?
- A. Elevated serum calcium
- B. Low serum magnesium
- C. Low serum calcium
- D. Elevated serum potassium
Correct Answer: C
Rationale: The correct answer is C: Low serum calcium. Hand spasms and paresthesia are indicative of potential hypocalcemia, which is characterized by low serum calcium levels. Elevated serum calcium (Choice A) is not consistent with the symptoms described. Low serum magnesium (Choice B) and elevated serum potassium (Choice D) are not typically associated with hand spasms and paresthesia.
A client is admitted with acute low back pain. What action should the nurse implement to promote comfort?
- A. Ambulate with a walker for upper body support
- B. Perform abdominal curls to stretch the back muscles
- C. Position in semi-Fowler's with the knees flexed
- D. Encourage straight leg raises while lying supine
Correct Answer: C
Rationale: Positioning the client in semi-Fowler's with the knees flexed is the most appropriate action to promote comfort in a client with acute low back pain. This position helps alleviate low back pain by reducing the pressure on the spine and supporting its natural curvature. Ambulating with a walker could strain the back, performing abdominal curls may exacerbate the pain, and straight leg raises while lying supine could cause further discomfort. Therefore, only positioning the client in semi-Fowler's with the knees flexed is the correct choice for promoting comfort in this scenario.
In the Emergency Department, a female client discloses that she was raped last night. Which question is most important for the nurse to ask?
- A. Does she know the person who raped her?
- B. Has she taken a bath since the rape occurred?
- C. Is the place where she lives a safe place?
- D. Did she report the rape to the police department?
Correct Answer: A
Rationale: The most important question for the nurse to ask in this situation is whether the client knows the person who raped her. This question is crucial for assessing additional safety concerns, providing appropriate support, and determining the need for forensic evidence collection. Choices B, C, and D are not as critical in the immediate assessment and response to a rape victim. Asking about bathing, the safety of her home, or reporting to the police may be important but are secondary to identifying the perpetrator for safety and legal reasons.
The nurse notes that an older adult client has a moist cough that increases in severity during and after meals. Based on this finding, what action should the nurse take?
- A. Encourage the client to perform deep breathing exercises daily.
- B. Offer the client additional clear fluids frequently.
- C. Collect a sputum specimen immediately.
- D. Request a consultation to confirm dysphagia
Correct Answer: D
Rationale: The correct answer is D. The moist cough that worsens during and after meals suggests possible dysphagia, a condition related to swallowing difficulties. Requesting a consultation for dysphagia is essential for an accurate diagnosis and appropriate management. Encouraging the client to perform deep breathing exercises (choice A) may not address the underlying issue of dysphagia. Offering additional clear fluids (choice B) may not be appropriate for someone with swallowing difficulties. Collecting a sputum specimen (choice C) is not the priority in this scenario as the focus should be on identifying and managing the swallowing problem.