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A healthcare provider is assessing a newborn who has a patent ductus arteriosus. Which of the following findings should the provider expect?
- A. Continuous murmur.
- B. Absent peripheral pulses.
- C. Increased blood pressure.
- D. Bounding pulses.
Correct Answer: A
Rationale: A continuous murmur is a classic finding in a newborn with patent ductus arteriosus. This murmur is typically heard between the first and second heart sounds and throughout systole. Absent peripheral pulses (choice B) are not typically associated with patent ductus arteriosus. Increased blood pressure (choice C) and bounding pulses (choice D) are not commonly seen with this condition. Therefore, the correct answer is A.
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A client reports intimate partner violence to a nurse. What is the nurse's priority action?
- A. Develop a safety plan with the client.
- B. Refer the client to a community support group.
- C. Determine if the client has any injuries.
- D. Ensure the client has access to legal services.
Correct Answer: A
Rationale: The correct answer is to develop a safety plan with the client. When a client reports intimate partner violence, the priority is ensuring their immediate safety. Developing a safety plan involves identifying safe places, emergency contacts, and strategies to protect the client from harm. Referring the client to a community support group (Choice B) can be helpful but not the immediate priority. While determining if the client has any injuries (Choice C) is important for assessing their physical well-being, the priority is to ensure their safety. Ensuring the client has access to legal services (Choice D) is crucial, but it is not the immediate priority when the client is at risk of violence.
A nurse is providing discharge teaching to a client who has a new prescription for albuterol. Which of the following instructions should the nurse include?
- A. You should take this medication at bedtime.
- B. You might experience palpitations while taking this medication.
- C. You should rinse your mouth after using this medication.
- D. You should avoid eating before taking this medication.
Correct Answer: C
Rationale: The correct answer is C: 'You should rinse your mouth after using this medication.' When providing discharge teaching for a client prescribed albuterol, the nurse should include the instruction to rinse the mouth after each use. This is important to prevent dry mouth and oral infections. Choice A is incorrect as albuterol is usually taken during the day to manage symptoms, not at bedtime. Choice B is incorrect as palpitations are not a common side effect of albuterol. Choice D is incorrect as there is no specific requirement to avoid eating before taking albuterol.
A nurse is planning care for a client who is experiencing acute mania. What intervention should the nurse include?
- A. Encourage the client to take frequent rest periods.
- B. Withdraw TV privileges if the client does not attend group therapy.
- C. Place the client in seclusion during periods of anxiety.
- D. Encourage the client to spend time in the day room.
Correct Answer: A
Rationale: The correct answer is A: Encourage the client to take frequent rest periods. During acute mania, individuals often experience high levels of energy, decreased need for sleep, and increased activity levels. Encouraging the client to take frequent rest periods can help prevent exhaustion and promote better self-regulation. Choice B is incorrect because withdrawing TV privileges may not be directly related to managing acute mania. Choice C is incorrect as placing the client in seclusion can exacerbate feelings of anxiety and agitation. Choice D is incorrect as spending time in the day room may not address the need for rest and relaxation that is crucial during acute mania.
A nurse is preparing to perform postmortem care for a client. Which of the following actions should the nurse take?
- A. Place the client's dentures in a labeled container
- B. Remove the client's IV lines
- C. Place the client's body in a semi-fowler's position
- D. Lower the client's head of the bed
Correct Answer: B
Rationale: The correct action for the nurse to take when preparing to perform postmortem care is to remove the client's IV lines. This step is essential to help maintain the dignity and appearance of the body. Placing the client's dentures in a labeled container (Choice A) is not a priority during postmortem care as the focus is on the body's preparation. While positioning the body in a semi-fowler's position (Choice C) or lowering the client's head of the bed (Choice D) are common practices for living clients to prevent aspiration, they are not necessary after death. Therefore, the immediate action of removing IV lines is most appropriate in this situation.
A nurse is reviewing the medical record of a client with major depressive disorder who is taking fluoxetine. Which of the following findings should the nurse report to the provider?
- A. Heart rate of 80/min
- B. Blood pressure 130/80 mm Hg
- C. Weight gain of 2.2 kg (5 lb) in 1 week
- D. Temperature of 37.2°C (99°F)
Correct Answer: C
Rationale: The correct answer is C. A weight gain of 2.2 kg (5 lb) in 1 week can indicate fluid retention, a serious side effect of fluoxetine that should be reported to the provider. Choices A, B, and D are within normal ranges and are not alarming findings that would require immediate reporting to the provider. A heart rate of 80/min, blood pressure of 130/80 mm Hg, and a temperature of 37.2°C (99°F) are all within normal limits and not typically concerning in a client taking fluoxetine.