Nokea
Which of the following actions should the nurse include in the plan?
- A. Maintain eye contact with the newborn during feedings
- B. Minimize noise in the newborn's environment.
- C. Swaddle the newborn with his legs extended
- D. Administer naloxone to the newborn.
Correct Answer: B
Rationale: Minimizing noise and stimuli helps to reduce symptoms of neonatal abstinence syndrome.
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Complete the following sentence by using the list of options. The client is at risk of----- as evidenced by-------
- A. fluid volume overload
- B. anemia
- C. hypostatic pneumonia
- D. calorie deficiency
- E. orthostatic hypotension
- F. immobility
Correct Answer: C,F
Rationale: Immobility increases the risk of hypostatic pneumonia, especially in clients with paraplegia.
Which of the following information should the nurse include?
- A. This type of seizure lasts 30 to 60 seconds.
- B. This type of seizure can be mistaken for daydreaming.
- C. This type of seizure has a gradual onset.
- D. The child usually has an aura prior to onset.
Correct Answer: B
Rationale: Absence seizures are often brief and can easily be mistaken for daydreaming.
A nurse is performing postmortem care for a recently deceased client prior to the client's family visit. Which of the following actions should the nurse plan to take?
- A. Cross the client's arms across their chest.
- B. Hold the client's eyes shut for a few seconds
- C. Place the client in a high-Fowler's position
- D. Remove the client's dentures from their mouth.
Correct Answer: B
Rationale: The correct answer is B: Hold the client's eyes shut for a few seconds. This action is important to maintain a dignified appearance for the deceased client and to create a peaceful and respectful image for the family during their visit. Crossing the client's arms (A) or placing them in a high-Fowler's position (C) may not be necessary and can be considered unnecessary handling of the body. Removing the client's dentures (D) is not typically part of postmortem care unless specifically instructed. Holding the eyes shut briefly is a culturally sensitive and respectful practice that can help create a serene appearance for the family.
The nurse should expect a prescription for which of the following laboratory tests?
- A. Platelet count
- B. Potassium level
- C. Creatinine clearance
- D. Prealbumin
Correct Answer: A
Rationale: Petechiae and ecchymoses suggest thrombocytopenia warranting platelet count evaluation.
A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr. Which of the following interventions should the nurse anticipate?
- A. Initiate continuous bladder irrigation.
- B. Administer a fluid bolus
- C. Clamp the catheter tubing for 30 min.
- D. Obtain a urine specimen for culture and sensitive
Correct Answer: B
Rationale: The correct answer is B: Administer a fluid bolus. The dark yellow urine output at 25 mL/hr indicates concentrated urine and potential dehydration. Administering a fluid bolus would help improve hydration status and increase urine output. Continuous bladder irrigation (A) is not indicated as there is no indication of bladder obstruction. Clamping the catheter tubing (C) can lead to urinary retention and should not be done without a specific reason. Obtaining a urine specimen for culture (D) is important, but addressing the dehydration issue takes priority.