Nokea
A 4-month-old is brought to the well-baby clinic for immunization. In addition to the DPT and polio vaccines, the baby should receive:
- A. Hib titer
- B. Mumps vaccine
- C. Hepatitis B vaccine
- D. MMR
Correct Answer: C
Rationale: At 4 months, the hepatitis B vaccine is part of the standard immunization schedule, along with DPT and polio vaccines.
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A client is admitted with symptoms of vertigo and syncope. Diagnostic tests indicate left subclavian artery obstruction. What additional findings would the nurse expect?
- A. Memory loss and disorientation
- B. Numbness in the face, mouth, and tongue
- C. Radial pulse differences over 10 bpm
- D. Frontal headache with associated nausea or emesis
Correct Answer: C
Rationale: Subclavian artery obstruction can cause reduced blood flow to the arm, leading to radial pulse differences between arms, a hallmark of conditions like subclavian steal syndrome.
A 60-year-old diabetic is taking glyburide (Diabeta) 1.25 mg daily to treat Type II diabetes mellitus. Which statement indicates the need for further teaching?
- A. I will keep candy with me just in case my blood sugar drops.
- B. I need to stay out of the sun as much as possible.
- C. I often skip dinner because I don't feel hungry.
- D. I always wear my medical identification.
Correct Answer: C
Rationale: Skipping meals while on glyburide increases hypoglycemia risk, indicating a need for further teaching.
The nurse is caring for a laboring client who is on an oxytocin infusion. The client experiences seven contractions in a 10-minute time period. The fetal heart rate tracing is a category III. Which action should the nurse take?
- A. discontinue the oxytocin infusion
- B. increase the oxytocin infusion rate
- C. decrease the oxytocin infusion rate by half
- D. reposition the client into a high-Fowler's position
Correct Answer: A
Rationale: A category III fetal heart rate tracing indicates fetal distress, and seven contractions in 10 minutes suggest uterine hyperstimulation. Discontinuing oxytocin is the priority to reduce fetal stress.
The nurse is observing the respirations of a client when she notes that the respiratory cycle is marked by periods of apnea lasting from 10 seconds to 1 minute. The apnea is followed by respirations that gradually increase in depth and frequency. The nurse should document that the client is experiencing:
- A. Cheyne-Stokes respirations
- B. Kussmaul respirations
- C. Biot respirations
- D. Diaphragmatic respirations
Correct Answer: A
Rationale: Cheyne-Stokes respirations are characterized by periods of apnea followed by increasing depth and frequency of breaths.
A 6-month-old client is placed on strict bed rest following a hernia repair. Which toy is best suited to the client?
- A. Colorful crib mobile
- B. Hand-held electronic games
- C. Cars in a plastic container
- D. 30-piece jigsaw puzzle
Correct Answer: A
Rationale: A colorful crib mobile is age-appropriate and safe for a 6-month-old on bed rest, providing visual stimulation.