Nokea
A newborn weighed 7 pounds 2 ounces at birth. The nurse assesses the newborn at home 2 days later and finds the weight to be 6 pounds 7 ounces. What should the nurse tell the parents about this weight loss?
- A. The newborn needs additional assessments
- B. The mother should breast feed more often
- C. A change to formula is indicated
- D. The loss is within normal limits
Correct Answer: D
Rationale: The loss is within normal limits. A newborn is expected to lose 5-10% of the birth weight in the first few days post-partum because of changes in elimination and feeding.
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While giving care to a 2 year-old client, the nurse should remember that the toddler's tendency to say 'no' to almost everything is an indication of what psychosocial skill?
- A. Stubborn behavior
- B. Rejection of parents
- C. Frustration with adults
- D. Assertion of control
Correct Answer: D
Rationale: Assertion of control. Negativity is a normal behavior in toddlers. The nurse must be aware that this behavior is an important sign of the child's progress from dependency to autonomy and independence.
Which of the following actions, if performed by the nurse before the application of a cast, is MOST important?
- A. Check the radial pulses bilaterally and compare.
- B. Evaluate the skin temperature and tissue turgor in the area.
- C. Assess sensation of each foot while the girl closes her eyes.
- D. Apply baby powder to decrease skin irritation under the cast.
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) correct-assess neurovascular status, check pain, pallor, paralysis, paresthesia, pulselessness (2) assessment, temperature indicates decreased circulation, but is subjective and not most important (3) assessment, upper (not lower) extremity fracture (4) implementation, should not be done because it would increase skin irritation
The nurse is caring for a client who is receiving heparin 5,000 units subcutaneously every 12 hours. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Platelet count of 100,000/mm^3.
- B. INR of 1.2.
- C. PTT of 40 seconds.
- D. Hemoglobin of 14 g/dL.
Correct Answer: A
Rationale: A platelet count of 100,000/mm^3 suggests thrombocytopenia, a serious complication of heparin therapy, increasing bleeding risk and possibly indicating heparin-induced thrombocytopenia. Options B, C, and D are normal or less concerning: INR and PTT are not significantly affected by subcutaneous heparin, and hemoglobin 14 g/dL is normal.
Triage refers to the classification of injury severity during a disaster. Which of the following clients should receive priority during triage?
- A. Open fractures of the tibia and fibula
- B. Burns of the head and neck
- C. Crushing injury of the arm
- D. Contusions and lacerations of the head without loss of consciousness
Correct Answer: B
Rationale: Burns to the head and neck are prioritized due to potential airway compromise, a life-threatening condition. Open fractures, crushing injuries, and minor head injuries are less immediately critical.
Which laboratory result would be expected during the emergent phase of a burn injury?
- A. Glucose 100 mg/dl
- B. Potassium 3.5 mEq/l
- C. Sodium 142 mEq/l
- D. Albumin 4.2 gm/dl
Correct Answer: A
Rationale: Glucose levels rise as a result of the stress response during the emergent phase. Answers B, C, and D are within normal range. K+ and Na+ would be elevated, whereas albumin would be lowered during the emergent period due to increased permeability.