Nokea
A 6-month-old has had a pyloromyotomy to correct a pyloric stenosis. Three days after surgery, the parents have placed their infant in his own infant seat (see fi gure). The nurse should do which of the following?
- A. Reposition the infant to the left side.
- B. Ask the parents to put the infant back in his crib
- C. Remind the parents that the infant cannot use a pacifier now.
- D. Tell the parents they have positioned their infant correctly
Correct Answer: D
Rationale: Following pyloromyotomy the infant should be positioned with the head elevated and slightly on the right side to promote gastric emptying; the parents have positioned their infant correctly. The infant should be positioned on the right side, not the left side. When the child is in a crib, the head can be elevated and the infant can be propped on the right side. The infant can use a pacifi er if needed.
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What is the term that is used to describe a healthcare related incident or accident that may have possibly led to client harm?
- A. An adverse event
- B. A root cause
- C. A healthcare acquired event
- D. A sentinel event
Correct Answer: A
Rationale: An adverse event is a healthcare-related incident that may have led to client harm, such as medication errors or falls.
When using crutches, the client should be instructed to bear weight primarily on the:
- A. Axillae
- B. Elbows
- C. Upper arms
- D. Hands
Correct Answer: D
Rationale: Weight should be borne on the hands when using crutches to prevent nerve damage from pressure on the axillae. Elbows and upper arms are not primary weight-bearing areas.
When preparing to draw up 8 units of a short-acting insulin and 20 units of a long-acting insulin in the same syringe, the nurse should:
- A. Inject air in the vial with the long-acting insulin first.
- B. Draw up the long-acting insulin first.
- C. Draw up either insulin first.
- D. Use a high-dose insulin syringe.
Correct Answer: C
Rationale: Either insulin can be drawn up first, as long as air is injected into both vials in the reverse order and clear (short-acting) is drawn before cloudy (long-acting).
A client with a history of depression is prescribed duloxetine (Cymbalta). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild headache.
- B. Increased blood pressure.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Duloxetine can cause increased blood pressure, requiring immediate reporting to prevent cardiovascular complications.
A client with a suspected stroke is admitted to the emergency department. What is the nurse's priority action?
- A. Administer aspirin as ordered.
- B. Assess neurological status.
- C. Prepare for a CT scan.
- D. Monitor blood pressure.
Correct Answer: B
Rationale: Assessing neurological status is the priority to establish a baseline and detect changes in a suspected stroke, guiding urgent interventions.