Nokea
A healthcare professional is reviewing the arterial blood gas results for a client in the ICU who has kidney failure and determines the client has respiratory acidosis. Which of the following findings should the healthcare professional expect?
- A. Widened QRS complexes
- B. Hyperactive deep tendon reflexes
- C. Bounding peripheral pulses
- D. Warm, flushed skin
Correct Answer: A
Rationale: Respiratory acidosis is characterized by an increase in carbon dioxide levels in the blood, leading to acidosis. This condition can affect the heart's electrical conduction system, resulting in widened QRS complexes on an electrocardiogram (ECG). Hyperactive deep tendon reflexes, bounding peripheral pulses, and warm, flushed skin are not typically associated with respiratory acidosis.
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On examination the hands and feet of a 6 hours old infant is cyanotic without signs of distress. The nurse should document these findings as:
- A. Potential for respiratory distress
- B. Poor oxygenation
- C. Cold stress
- D. Acrocyanosis
Correct Answer: D
Rationale: Acrocyanosis is a condition commonly seen in newborns where the hands and feet appear blue or purple in color due to decreased circulation in the peripheral blood vessels. It is usually a normal finding in newborns and is not associated with distress or poor oxygenation. Unlike central cyanosis which indicates a more serious underlying issue affecting oxygen levels in the blood, acrocyanosis is a benign and self-limiting condition. It is important for the nurse to recognize and document acrocyanosis to differentiate it from other potentially concerning conditions.
A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Provide a stimulating environment
- B. Monitor blood glucose level every hr.
- C. Initiate seizure precautions.
- D. Place the infants on his back with legs extended.
Correct Answer: C
Rationale: Neonatal abstinence syndrome (NAS) occurs in infants who are exposed to addictive substances in utero, typically opioids. The signs of NAS can include irritability, tremors, feeding difficulties, and seizures. Therefore, it is essential for the nurse to initiate seizure precautions when caring for an infant with signs of NAS. This includes ensuring a safe environment, padding the crib, monitoring closely for seizure activity, and having emergency medications readily available if needed. Providing a stimulative environment (Option A) would be inappropriate as it can exacerbate symptoms of NAS. While monitoring blood glucose (Option B) is important in some situations, such as for infants of diabetic mothers, it is not the priority in NAS. Placing the infant on their back with legs extended (Option D) does not directly address the immediate concerns related to NAS.
A person is admitted to the antepartum floor for hypertension. The person is Hispanic and speaks fluent English. They tell the nurse they have been seeing a curandero, or traditional healer, for the past several years. What is the best initial response from the nurse?
- A. Ask the patient for a list of all herbs, plants, and special diets they are currently taking.
- B. Educate the person on why adherence to a Western medical treatment plan is better for their health.
- C. Inform the person that the treatment they have been receiving from the curandero is not evidence based.
- D. Tell the person that they are not considering the health of their baby by using these traditions.
Correct Answer: A
Rationale: Understanding the patient's use of traditional healing practices ensures safe integration with Western medicine.
The nurse is teaching a client about signs of postpartum hemorrhage. What statement indicates understanding?
- A. Passing a few clots is normal.
- B. Soaking one pad in an hour is concerning.
- C. Heavy bleeding stops within 48 hours.
- D. I should ignore mild cramping.
Correct Answer: B
Rationale: Soaking a pad in an hour may indicate postpartum hemorrhage and should be reported immediately.
A woman is being treated for preterm labor with magnesium
- A. The nurse is concerned that the patient is experiencing early drug toxicity. Which assessment finding by the nurse indicates early toxicity?
- B. Patellar reflexes are weak and absent
- C. RR 16
- D. Fetal HR 120
Correct Answer: E
Rationale: The correct assessment finding that indicates early toxicity related to magnesium sulfate administration is the patient complaining of feeling flushed and warm. These symptoms could indicate that the patient is experiencing magnesium toxicity, which can lead to vasodilation and hypotension. Other signs of magnesium toxicity include decreased deep tendon reflexes, respiratory depression, and loss of consciousness. It's essential for the nurse to recognize these early signs of toxicity and intervene promptly to prevent further complications.