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 hospice nurse is providing end-of-life care to a client who is experiencing anorexia and cachexia. Which interventions are appropriate? Select all that apply.
- A. Allow the client to refuse food if not feeling hungry
- B. Ask if the client is experiencing any pain or nausea
- C. Involve the client in meal planning and food selection
- D. Plan for loved ones to share mealtimes with the client
- E. Provide oral care before and after meals to alleviate dry mouth
Correct Answer: A,B,D,E
Rationale: Allowing food refusal (A) respects autonomy, assessing pain/nausea (B) addresses barriers to eating, shared mealtimes (D) provide comfort, and oral care (E) improves appetite. Meal planning (C) may overwhelm a cachectic client.
A client is diagnosed as having secondary Cushing's syndrome. The nurse knows that the client has most likely been taking which medication?
- A. Estrogen
- B. Penicillin
- C. Lovastatin
- D. Prednisone
Correct Answer: D
Rationale: Secondary Cushing's syndrome is often caused by long-term prednisone use, a corticosteroid mimicking cortisol excess. Estrogen, penicillin, or lovastatin do not cause this condition.
The nurse has reinforced teaching with the parent of a 3-year-old client who has acute diarrhea. Which of the following statements by the parent would require follow-up?
- A. I will apply a skin barrier cream to my child’s diaper area until the diarrhea subsides.
- B. I will encourage my child to drink small amounts of fluids at frequent intervals.
- C. I will feed my child a diet of bananas, rice, applesauce, and toast for the next few days.
- D. I will return to the clinic if I notice a decrease in my child’s urine output.
Correct Answer: C
Rationale: The BRAT diet (C) is outdated and may lack nutrients, risking prolonged recovery. Skin barrier cream (A), frequent fluids (B), and monitoring urine output (D) are appropriate for preventing skin breakdown, dehydration, and detecting complications.
Assessment of a client with a history of stroke reveals that the client understands and follows commands but answers questions with incorrect word choices. The nurse documents the presence of which communication deficit?
- A. Aphasia
- B. Apraxia
- C. Dysarthria
- D. Dysphagia
Correct Answer: A
Rationale: Aphasia (A) is a language disorder causing difficulty with word choice or expression, common in stroke affecting language centers. The client’s ability to follow commands but use incorrect words suggests expressive aphasia. Apraxia (B) affects motor planning, dysarthria (C) impairs speech articulation, and dysphagia (D) involves swallowing difficulties, none of which match the described deficit.
The nurse is providing first aid at an outdoor festival when a client reports dizziness and weakness. The client is flushed, sweating, nauseated, and slightly tachycardic. Which action is most appropriate at this time?
- A. Call emergency medical services and place ice packs on the client’s axilla and groin
- B. Encourage the client to leave the venue to visit a health care provider
- C. Evaluate whether the client may be intoxicated
- D. Move the client to an air-conditioned booth and provide a cool sports drink
Correct Answer: D
Rationale: Symptoms suggest heat exhaustion. Moving to a cool area and providing fluids (D) is the first step. EMS (A) is premature, leaving (B) delays care, and intoxication (C) is not indicated.