Nokea
A client going to surgery tells the nurse that she is an active member of the Jehovah's Witness religion. The nurse is aware that the client's spiritual beliefs prohibit:
- A. The use of antibiotics and antivirals
- B. The use of medication from pork sources
- C. The eating of shellfish
- D. The use of blood or blood products
Correct Answer: D
Rationale: Jehovah's Witnesses prohibit blood transfusions and blood products due to religious beliefs. Other options are not typically restricted.
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A 4 lb 10 oz baby boy delivered at 32 weeks gestation. The infant is admitted to the neonatal intensive care unit and placed in an incubator. He has mottling of the skin and acrocyanosis with irregular respirations of 60.
The nurse should recognize these findings as signs of
- A. hypoglycemia.
- B. cold stress.
- C. birth asphyxia.
- D. hypovolemia.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) blood sugar less than 25 mg/dL, would see cyanosis, apnea, tachypnea, irregular respirations, diaphoresis, jitteriness, weak cry, lethargy, convulsions, coma (2) correct-symptoms describe cold stress (3) would see meconium stained amniotic fluid (4) would see symptoms of shock
Hospital staff requests that the parents with a Greek heritage of a hospitalized infant remove the amulet from around the child's neck. The parents refuse. The nurse understands that the parents may be concerned about
- A. Mental development delays
- B. Evil eye or envy of others
- C. Fright from spiritual beings
- D. Balance in body systems
Correct Answer: B
Rationale: Evil eye or envy of others. In Greek culture, amulets protect against 'matiasma' or the evil eye, especially for children.
An 8-year-old boy falls off the swings at school and hits his head. He is examined by a physician at an urgent care center, diagnosed with a minor head injury, and sent home.
Which of the following statements, if made by the mother to the nurse, would require further teaching by the nurse?
- A. He should avoid blowing his nose or cleaning his ears for two days.'
- B. I should wake him every 3 hours tonight and tomorrow night to check him.'
- C. I can give him Tylenol every 4 hours if he complains of a headache.'
- D. He will be well enough to play in his soccer game tomorrow.'
Correct Answer: D
Rationale: Strategy: 'Further teaching' indicates an incorrect response. (1) prevents increased pressure on area (2) should check level of consciousness and orientation every 3-4 hours (3) avoid use of sedatives, sleeping pills, alcohol with head injuries (4) correct-no strenuous activity for 48 hours
The nurse is caring for a client who is receiving a continuous IV infusion of heparin. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. PTT of 90 seconds.
- B. INR of 1.0.
- C. Platelet count of 150,000/mm^3.
- D. Hemoglobin of 13 g/dL.
Correct Answer: A
Rationale: A PTT of 90 seconds is above the therapeutic range for heparin (60–80 seconds), increasing bleeding risk, requiring immediate adjustment. Options B, C, and D are normal: INR is unaffected, platelet count 150,000/mm^3 is adequate, and hemoglobin 13 g/dL is normal.
A client before administration of captopril (Capoten).
The MOST appropriate nursing action before administration of captopril (Capoten) would be to check the client's
- A. apical pulse for 60 seconds.
- B. blood pressure.
- C. urine output.
- D. temperature.
Correct Answer: B
Rationale: Strategy: Think about each answer choice and how it relates to Capoten. (1) important, but not a priority (2) correct-is an antihypertensive that necessitates that a BP be assessed prior to administration (3) important, but not priority (4) unnecessary to assess prior to the administration of the medication