Nokea
A baby is born precipitously in the ER. The nurses initial action should be to:
- A. Establish an airway for the baby
- B. Ascertain the condition of the fundus
- C. Quickly tie and cut the umbilical cord
- D. Move mother and baby to the birthing unit
Correct Answer: A
Rationale: The initial action that the nurses should take after a baby is born precipitously in the ER is to establish an airway for the baby. This is crucial for ensuring the baby's ability to breathe properly and for their overall well-being. Clearing the airway helps prevent complications such as asphyxia and ensures that the baby is receiving adequate oxygen. Once the airway has been established and the baby's breathing is stable, then other assessments and actions can be taken.
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Another girl was bitten by a poisonous snake. All of the following are true except
- A. The victim of a snake bite should be made to exercise the bitten extremity to hasten circulation
- B. The bite of a poisonous snake is distinguished by two fang marks
- C. Immediate severe pain and swelling distinguished the bite of a poisonous snake
- D. The tourniquet should be tight enough to prevent superficial circulation of blood thus stopping absorption of the poison
Correct Answer: A
Rationale: When it comes to snake bites, one should not exercise the bitten extremity as it can increase the spread of venom in the body. Moving the affected limb can potentially lead to the venom spreading more quickly through the lymphatic system and into the bloodstream. Therefore, it is essential to keep the victim as calm and still as possible to minimize the effects of the venom. Proper first aid for snake bites includes keeping the victim calm, immobilizing the bitten limb, and seeking immediate medical attention.
The client with trigeminal neuralgia tells the nurse that acetaminophen (Tylenol) is taken daily for the relief of generalized discomfort. Which laboratory value would indicate toxicity associated with the medication?
- A. Sodium level of 140 mEq/l.
- B. Direct bilirubin level of 2 mg/dl
- C. Prothrombin time of 12 seconds
- D. Platelet count of 400,000/mm3
Correct Answer: B
Rationale: Acetaminophen toxicity can lead to hepatic injury, resulting in elevated liver enzymes, including bilirubin levels. Direct bilirubin is a specific marker for liver function and is typically elevated in cases of acetaminophen overdose or toxicity. Therefore, a direct bilirubin level of 2 mg/dl would indicate toxicity associated with acetaminophen use. Monitoring liver function tests, including bilirubin levels, is crucial when using acetaminophen long-term to prevent toxicity and liver damage.
A client in the terminal stage of cancer is receiving continuous infusion of morphine (Duramorph) for pain management. Which assessment finding suggests that the client is experiencing an adverse effect of this drug?
- A. Voiding of 350mL of concentrated urine in
- B. Irregular heart rate of 82 beats/min
- C. Pupils constricted and equal
- D. Respiratory rate of 8breaths/min
Correct Answer: D
Rationale: The assessment finding that suggests the client is experiencing an adverse effect of morphine (Duramorph) is a respiratory rate of 8 breaths/min. Morphine is a potent opioid analgesic that can cause respiratory depression as a side effect. When the respiratory rate decreases significantly, it indicates the potential for compromised breathing, which could progress to respiratory failure. This is a serious adverse effect that requires immediate attention and evaluation by healthcare providers. The client receiving continuous infusion of morphine should be closely monitored for signs of respiratory depression to prevent life-threatening consequences.
Which interventions should the nurse implement when caring for a family of a sudden infant death syndrome (SIDS) infant? (Select all that apply.)
- A. Allow parents to say goodbye to their infant.
- B. Once parents leave the hospital, no further follow-up is required.
- C. Arrange for someone to take the parents home from the hospital.
- D. Avoid requesting an autopsy of the deceased infant.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The ff are the tonometer measurements of five clients. Which of them has normal intraocular pressure (IOP)? Choose all that apply
- A. 8 mm Hg
- B. 25 mm Hg
- C. 11 mm Hg
- D. 28 mm Hg
Correct Answer: C
Rationale: Normal intraocular pressure (IOP) typically ranges between 10 and 21 mm Hg. For this reason, the tonometer measurements of 11 mm Hg and 20 mm Hg fall within the normal range. Therefore, clients with these IOP values (Option C and E) have normal intraocular pressure. The other options (A, B, and D) are outside the normal range for IOP and are therefore considered elevated.