Nokea
A nurse discovers a cyanotic newborn with excessive frothy mucus in the mouth. What should be the nurse’s first action?
- A. Administer 100% oxygen
- B. Auscultate the lungs
- C. Place infant in knee-chest position
- D. Suction the infant’s mouth
Correct Answer: D
Rationale: Suctioning the mouth (D) clears mucus, addressing potential airway obstruction causing cyanosis. Oxygen (A), auscultation (B), and positioning (C) are secondary until the airway is clear.
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The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by the nurse would be appropriate?
- A. Schedule the therapy thirty minutes after meals
- B. Teach the child not to cough during the treatment
- C. Continue the percussion to the rib cage area
- D. Place the child in a prone position for the therapy
Correct Answer: C
Rationale: Continue the percussion to the rib cage area. Percussion should target the rib cage to mobilize secretions effectively.
During an initial prenatal visit, the practical nurse is reviewing the history of a client at 10 weeks gestation. Which finding is a priority to report to the registered nurse?
- A. Client cares for a pet dog and a few outdoor cats
- B. Client has gained 4 lb (1.8 kg) during the pregnancy so far
- C. Client reports a nonodorous, milky white vaginal discharge
- D. Client swims in a pool for exercise three times per week
Correct Answer: A
Rationale: Pet cats (A) pose a toxoplasmosis risk, which can cause fetal harm, requiring immediate education and possible testing. Weight gain (B) is normal, milky discharge (C) is typical in pregnancy, and swimming (D) is safe.
When planning care for a woman who is admitted in labor, it is most important for the nurse to obtain which of the following information about the client?
- A. Age of the client and due date
- B. Frequency and duration of contractions
- C. Whether the membranes have ruptured
- D. Who will be assisting the woman during labor
Correct Answer: B
Rationale: Contraction frequency and duration indicate labor progress and urgency, guiding immediate care. Age, due date, membrane status, and support persons are secondary.
A client admitted with glaucoma is being treated with miotic (pilocarpine) eye drops. Following administration of the medication, the nurse will note:
- A. Dilation of the pupils
- B. Diminished redness of the sclera
- C. Decreased edema of the cornea
- D. Constriction of the pupils
Correct Answer: D
Rationale: Miotics, such as pilocarpine, are administered to the client with glaucoma to cause pupillary constriction, thereby lowering intraocular pressure. Answer A is incorrect because miotics constrict the pupil. Answer B is incorrect because miotics do not diminish redness. Answer C is incorrect because miotics do not decrease edema of the cornea.
The nurse is caring for a client who is experiencing hypotension and respiratory depression after administration of IV midazolam. The nurse should anticipate that the client will receive
- A. Acetylcysteine
- B. Benztropine
- C. Phentolamine
- D. Flumazenil
Correct Answer: D
Rationale: Midazolam, a benzodiazepine, can cause respiratory depression and hypotension in overdose. Flumazenil (D) is the specific antidote, reversing benzodiazepine effects. Acetylcysteine (A) treats acetaminophen overdose, benztropine (B) manages extrapyramidal symptoms, and phentolamine (C) treats hypertensive crises, none of which apply here.