Nokea
A neonate born 12 hours ago to a methadone maintained woman is exhibiting a hyperactive MORO reflex and slight tremors. The newborn passed one loose, watery stool. Which of these is a nursing priority?
- A. Hold the infant at frequent intervals.
- B. Assess for neonatal withdrawal syndrome
- C. Offer fluids to prevent dehydration
- D. Administer paregoric to stop diarrhea
Correct Answer: B
Rationale: Assess for neonatal withdrawal syndrome. These symptoms indicate possible opioid withdrawal, requiring immediate assessment.
You may also like to solve these questions
A client was struck on the head by a baseball bat during a robbery attempt. The nurse gives shift report to the oncoming nurse and conveys that the client's current Glasgow Coma Scale score is a '10.' Which other information is most important for the reporting nurse to include?
- A. Client's blood pressure was 120/80 mm Hg and pulse was 82/min recently
- B. Client's Glasgow Coma Scale score was '11' one hour ago
- C. Client believes that the current surroundings are a racetrack
- D. Client is allergic to penicillin and vancomycin
Correct Answer: B
Rationale: A decrease in Glasgow Coma Scale score from 11 to 10 in one hour indicates worsening neurological status, possibly due to increasing intracranial pressure, requiring urgent reporting.
The nurse has an order to administer ophthalmic drops and ophthalmic ointment to a client being treated for conjunctivitis. The nurse should:
- A. Apply the eye ointment and eye drops together.
- B. Apply the eye drops, wait 5 minutes, and apply the ointment.
- C. Apply the eye ointment, wait 30 minutes, and apply the eye drops.
- D. Ask the pharmacist to supply the two medications in the same form.
Correct Answer: B
Rationale: Applying drops first, then waiting 5 minutes before ointment, ensures proper absorption of both. Ointment first would block drops, and combining forms is unnecessary.
The nurse receives news of a local mass shooting. Stable clients need to be discharged to make room for newly admitted clients. Which client would the nurse identify as safe to recommend for discharge?
- A. Client on chemotherapy who started antibiotics today for cellulitis of the leg
- B. Client with asthma exacerbation who has not required oxygen or a nebulizer in 12 hours
- C. Client with diabetes who has nausea, abdominal pain, and vomiting
- D. Client with ulcerative colitis and diarrhea who has developed fever and vomiting
Correct Answer: B
Rationale: The client with resolved asthma exacerbation, not requiring oxygen or nebulizers for 12 hours, is stable and safe for discharge, unlike the others with active complications.
Which of these tests would the nurse expect to monitor for the evaluation of clients aged 18 and older with poor glycemic control?
- A. A glycosylated hemoglobin (A1c) should be performed during an initial assessment and during follow-up assessment, which should occur in longer than 3-month intervals
- B. A glycosylated hemoglobin is to be obtained at least two years
- C. A fasting glucose and a glycosylated hemoglobin is to be obtained at 3 months intervals after the initial assessment
- D. A glucose tolerance test, a fasting glucose and a glycosylated hemoglobin should be obtained at 6-month intervals after the initial assessment
Correct Answer: A
Rationale: The American Diabetes Association (ADA) recommends obtaining a glycosylated hemoglobin during an initial assessment and then routinely as part of continuing care for clients with poor glycemic control.
A triage nurse has these 4 clients arrive in the emergency department within a 15 minute period. Which client should the triage nurse send back to be seen first?
- A. A 2 month old infant with a history of rolling off the bed and has bulging fontanels with crying
- B. A teenager who got a singed beard while camping
- C. An elderly client with complaints of frequent liquid brown colored stools
- D. A middle aged client with intermittent pain behind the right scapula
Correct Answer: B
Rationale: A teenager who got a singed beard while camping. This client is in the greatest danger with a potential of respiratory distress, Any client with singed facial hair has been exposed to heat or fire in close range that could have caused damage to the interior of the lung. Note that the interior lining of the lung has no nerve fibers so the client will not be aware of swelling.