Nokea
A newborn has hyperbilirubinemia and is undergoing phototherapy with a fiberoptic blanket. Which safety measure is most important during this process?
- A. Regulate the neonate's temperature using a radiant heater
- B. Withhold feedings while under the phototherapy
- C. Provide water feedings at least every 2 hours
- D. Protect the eyes of neonate from the phototherapy lights
Correct Answer: C
Rationale: Provide water feedings at least every 2 hours. Protecting the eyes of the neonates is very important to prevent damage when under the ultraviolet lights, but since the blanket is used, extra protection of the eyes is unnecessary. It is recommended that the neonate remain under the lights for extended periods. The neonate's skin is exposed to the light and the temperature is monitored, but a heater may not be necessary. There is no reason to withhold feedings. Frequent water or feedings are given to help with the excretion of the bilirubin in the stool.
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The nurse is teaching a client with a new diagnosis of depression about fluoxetine (Prozac). Which of the following instructions should the nurse include?
- A. Take the medication at bedtime.
- B. Report any suicidal thoughts.
- C. Stop the medication if mood improves.
- D. Avoid regular mental health follow-ups.
Correct Answer: B
Rationale: Suicidal thoughts are a serious fluoxetine side effect, requiring immediate reporting. Options A, C, and D are incorrect.
A comatose patient who is incontinent.
The nurse should intervene if which of the following actions is noted?
- A. The nurse assistant answers the phone while wearing gloves.
- B. The nursing assistant log rolls the patient to provide back care.
- C. The nursing assistant places an incontinence pad under the patient.
- D. The nursing assistant positions the patient on the left side, head elevated.
Correct Answer: A
Rationale: Strategy: 'Nurse should intervene' indicates that you are looking for an incorrect action. (1) correct-contaminated gloves should be removed before answering the phone (2) correct way to roll a patient to maintain proper alignment (3) appropriate to use incontinence pad for this patient (4) appropriate position to prevent aspiration and protect the airway
The nurse is supervising care given to a group of patients on the unit. The nurse observes a staff member entering a patient's room wearing gown and gloves. The nurse knows that the staff member is caring for which of the following patients?
- A. An 18-month-old with respiratory syncytial virus.
- B. A 4-year-old with Kawasaki disease.
- C. A 10-year-old with Lyme's disease.
- D. A 16-year-old with infectious mononucleosis.
Correct Answer: A
Rationale: acute viral infection; requires contact precautions; assign to private room or with other RSV-infected children
The nurse is caring for a client with end stage renal disease. What action should the nurse take to assess for patency in a fistula used for hemodialysis?
- A. Observe for edema proximal to the site
- B. Irrigate with 5 ml of 0.9% Normal Saline
- C. Palpate for a thrill over the fistula
- D. Check color and warmth in the extremity
Correct Answer: C
Rationale: Palpate for a thrill over the fistula. A thrill indicates patency of the fistula.
The nurse is caring for a client who has psoriasis. Which observation by the nurse is most consistent with the diagnosis?
- A. The client has thick, yellow toenails.
- B. The client has open, weeping lesions.
- C. The skin lesions are multicolored.
- D. The pain follows a nerve root.
Correct Answer: B
Rationale: Psoriasis typically presents with dry, scaly plaques that may crack and weep, consistent with open lesions. Yellow nails, multicolored lesions, or nerve pain are unrelated.