Nokea
A client has had a cardiac catheterization. The left femoral dressing has a moderate amount of bloody drainage, and the client has severe pain in that area. The nurse should first:
- A. Assess the airway.
- B. Administer oxygen.
- C. Apply pressure to the site.
- D. Assess the pulse in the left extremity.
Correct Answer: C
Rationale: Applying pressure to the site controls bleeding, which is the priority in this scenario.
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Intussusception occurs when:
- A. Part of the intestine slides into another part of the intestine.
- B. The appendix ruptures.
- C. An ileostomy stoma retracts below the abdominal surface.
- D. Lungs are infiltrated.
Correct Answer: A
Rationale: Intussusception is a condition where one segment of the intestine telescopes into another, causing obstruction, most commonly in children.
The nurse includes which interventions in the plan of care for a newborn diagnosed with gastroschisis? Select all that apply.
- A. Place infant in an open crib.
- B. Maintain intravenous site and fluids.
- C. Plan time for parents to hold the infant.
- D. Position infant in a side-lying position with a blanket roll to support the viscera.
- E. Keep exposed viscera covered with sterile moistened saline gauze and plastic wrap.
Correct Answer: B,D,E
Rationale: Gastroschisis is an abdominal wall defect in which the viscera are outside the abdominal cavity and not covered with a sac. The infant is kept nothing by mouth (NPO) so that the intravenous (IV) site and fluids are maintained. The infant should be placed in a side-lying position and the viscera supported with a blanket roll to prevent vascular compromise to a torqued intestine. Before surgery, the exposed viscera should be kept covered with sterile moistened saline gauze and plastic wrap. Thermoregulation is critical, so the infant should be placed in a warmer crib, not an open crib. The movement of the infant should be minimized, so parents are not allowed to hold the infant before surgery.
After teaching a mother about the neonate's positive Babinski's reflex, the nurse determines that the mother understands the instructions when she says that a positive Babinski's reflex indicates:
- A. Possible partial paralysis.
- B. Possible lower limb defect.
- C. Immature central nervous system.
- D. Possible injury to nerves that innervate the legs.
Correct Answer: C
Rationale: A positive Babinski's reflex in neonates indicates an immature central nervous system, a normal finding that typically disappears by 1–2 years.
A client with a history of heart failure is prescribed metoprolol (Lopressor). The nurse should monitor the client for which of the following side effects?
- A. Hypertension.
- B. Bradycardia.
- C. Hyperglycemia.
- D. Weight loss.
Correct Answer: B
Rationale: Metoprolol, a beta-blocker, can cause bradycardia, requiring close monitoring of heart rate.
The administration of an intramuscular injection to a neonate should be given in the:
- A. Gluteus maximus muscle.
- B. Vastus lateralis muscle.
- C. Deltoid muscle.
- D. The sternocleidomastoid muscle.
Correct Answer: B
Rationale: The vastus lateralis is the preferred site for IM injections in neonates due to its large muscle mass and minimal risk of nerve or bone injury.