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A 5-month-old infant is admitted to the ER with a temperature of 103.6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:
- A. Periorbital edema
- B. Tenseness of the anterior fontanel
- C. Positive Babinski reflex
- D. Negative scarf sign
Correct Answer: B
Rationale: Tenseness of the anterior fontanel indicates increased intracranial pressure, a critical finding in bacterial meningitis in infants.
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The nurse is caring for a client following a Whipple procedure. The nurse notes that the drainage from the nasogastric tube is bile tinged in appearance and has increased in the past hour. The nurse should:
- A. Document the finding and continue to monitor the client
- B. Irrigate the drainage tube with 10 mL of normal saline
- C. Decrease the amount of intermittent suction
- D. Notify the physician of the findings
Correct Answer: D
Rationale: Increased bile-tinged drainage may indicate a complication, such as a leak, requiring physician notification.
The nurse is assessing a client for hypovolemia. Which laboratory result would help the nurse in confirming a volume deficit?
- A. Hematocrit 55%
- B. Potassium 5.0 mEq/L
- C. Urine specific gravity 1.016
- D. BUN 18 mg/dL
Correct Answer: A
Rationale: Hypovolemia causes hemoconcentration, increasing hematocrit (e.g., 55% is elevated). Potassium, urine specific gravity, and BUN within normal ranges don't confirm volume deficit.
The nurse has orders for dopamine at 20 mcg/kg/min. The bag has 500 mg of dopamine in 500 mL. The client weighs 60 kg. What rate will the nurse set?
Correct Answer: 72 mL/hr
Rationale: Dose: 20 mcg/kg/min × 60 kg = 1200 mcg/min. Concentration: 500 mg/500 mL = 1 mg/mL = 1000 mcg/mL. Rate: 1200 mcg/min ÷ 1000 mcg/mL = 1.2 mL/min × 60 min/hr = 72 mL/hr.
The nurse is assisting a client with diverticulitis to select appropriate foods. Which food should be avoided?
- A. Bran
- B. Fresh peach
- C. Tomato and cucumber salad
- D. Dinner roll
Correct Answer: C
Rationale: Clients with diverticulitis should avoid foods with seeds, such as tomatoes and cucumbers, as they can irritate diverticula. Bran, peaches, and dinner rolls are generally safe.
The nurse is delegating tasks to an experienced, unlicensed assistive personnel (UAP). Which of the following clients should the nurse delegate to the UAP?
- A. a client with multiple pressure ulcers requiring daily dressing changes
- B. a client with a permanent tracheostomy requiring daily tracheostomy care
- C. a client recovering from pneumonia with orders to ambulate in the hall BID
- D. a client who just received pain medication and needs to have her pain level assessed in 30 minutes
Correct Answer: C
Rationale: Ambulating a client is within a UAP’s scope, requiring minimal clinical judgment, unlike wound care, tracheostomy care, or pain assessment.