Nokea
As a part of a 9 pound full-term newborn's assessment, the nurse performs a dextro-stick at 1 hour post birth. The serum glucose reading is 45 mg/dl. What action by the nurse is appropriate at this time?
- A. Give oral glucose water
- B. Notify the pediatrician
- C. Repeat the test in 2 hours
- D. Check the pulse oximetry reading
Correct Answer: C
Rationale: Repeat the test in 2 hours. This blood sugar is within the normal range for a full-term newborn. Normal values are: Premature infant: 20-60 mg/dl or 1.1-3.3 mmol/L, Neonate: 30-60 mg/dl or 1.7-3.3 mmol/L, Infant: 40-90 mg/dl or 2.2-5.0 mmol/L. Critical values are: Infant: <40 mg/dl and in a Newborn: <30 and >300 mg/dl. Because of the increased birth weight which can be associated with diabetes mellitus, repeated blood sugars will be drawn.
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Parents are concerned that their 11 year-old child is a very picky eater. The nurse suggests which of the following as the best initial approach?
- A. Consider a liquid supplement to increase calories
- B. Discuss consequences of an unbalanced diet with the child
- C. Provide fruit, vegetable and protein snacks
- D. Encourage the child to keep a daily log of foods eaten
Correct Answer: B
Rationale: Discuss consequences of an unbalanced diet with the child. It is important to educate the preadolescent as to appropriate diet, and the problems that might arise if diet is not adequate.
Which of the following assessment findings, if observed by the nurse, would support this diagnosis?
- A. Buffalo hump, hyperglycemia, and hypernatremia.
- B. Nervousness, tachycardia, and intolerance to heat.
- C. Lethargy, weight gain, and intolerance to cold.
- D. Irritability, moon face, and dry skin.
Correct Answer: A
Rationale: Strategy: Think about each answer choice and how it relates to Cushing's syndrome. (1) correct-Cushing's syndrome is characteristic of these assessments, as are weight gain, moon face, purple striae, osteoporosis, mood swings, and high susceptibility to infections (2) symptoms of hyperthyroidism (3) symptoms of hypothyroidism (myxedema) (4) symptoms of hypoparathyroidism
The nurse is caring for a client with a history of spinal cord injury.
- A. Which intervention is most effective for preventing autonomic dysreflexia in a client with a spinal cord injury?
- B. Monitor blood pressure regularly.
- C. Administer analgesics for pain.
- D. Keep the bladder empty.
- E. Encourage a low-fiber diet.
Correct Answer: C
Rationale: Keeping the bladder empty prevents distension, a common trigger for autonomic dysreflexia, a life-threatening hypertensive crisis in spinal cord injury. Blood pressure monitoring detects it, analgesics are irrelevant, and high-fiber diets prevent constipation.
The nurse is caring for a client with chronic kidney disease who is receiving epoetin alfa (Epogen). Which of the following laboratory results should the nurse report immediately?
- A. Hemoglobin 14 g/dL.
- B. Potassium 4.5 mEq/L.
- C. Creatinine 3.0 mg/dL.
- D. Calcium 9.0 mg/dL.
Correct Answer: A
Rationale: A hemoglobin of 14 g/dL is too high, risking hypertension or thrombosis with epoetin alfa. Options B, C, and D are expected or normal.
Which of the following is the MOST appropriate action for the nurse to take?
- A. Assess the cast for wet spots and increase air circulation in the room.
- B. Check the circulation in his casted extremity and change the client's position.
- C. Take the client's temperature and observe him for other signs of infection.
- D. Medicate the client for pain and notify the physician of his complaint.
Correct Answer: B
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) heat is sign of pressure (2) correct-heat is sign of pressure, pressure limits circulation (3) too early to see signs of infection (4) all complaints must be investigated, medication would mask signs of pressure, assessment first step