Nokea
A nurse discusses with parents the procedures that will be performed on their neonate immediately after delivery. The nurse determines that the instructions have been understood when the client states that what will be done to the neonate first?
- A. The neonate will be suctioned.
- B. The neonate will be dried and stimulated.
- C. The neonate will be given oxygen.
- D. The neonate's umbilical cord will be cut.
Correct Answer: A
Rationale: Suctioning the neonate's airway is the first priority to ensure a clear airway and promote breathing immediately after delivery.
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A client with a history of cystitis is admitted to the hospital with a diagnosis of pyelonephritis. The nurse should assess the client for which of the following?
- A. Suprapubic pain.
- B. Dysuria.
- C. Urine retention.
- D. Costovertebral tenderness.
Correct Answer: D
Rationale: Costovertebral tenderness is a hallmark of pyelonephritis, indicating kidney involvement, unlike the other symptoms, which are more typical of cystitis.
A client with a diagnosis of breast cancer is prescribed exemestane (Aromasin). The nurse should instruct the client to report which of the following side effects immediately?
- A. Hot flashes.
- B. Bone pain.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Bone pain may indicate bone loss or metastasis, a serious side effect of exemestane requiring immediate reporting.
A client with a history of depression is prescribed fluoxetine (Prozac). The nurse should instruct the client to report which of the following side effects?
- A. Insomnia.
- B. Bradycardia.
- C. Hypotension.
- D. Weight gain.
Correct Answer: A
Rationale: Fluoxetine commonly causes insomnia, which should be reported to manage treatment.
Which nursing assessment findings indicate normal vital signs in a newborn infant?
- A. Pulse, 112; respiratory rate, 24
- B. Pulse, 124; respiratory rate, 28
- C. Pulse, 144; respiratory rate, 48
- D. Pulse, 164; respiratory rate, 55
Correct Answer: C
Rationale: The normal pulse rate for a newborn is 120 to 160. The normal respiratory rate for a newborn infant is 30 to 60 breaths per minute. Therefore, the other options are incorrect.
Homocysteine may be cleared from the blood with the help of which of the following vitamins?
- A. Vitamin C
- B. Vitamin E
- C. Vitamin K
- D. Vitamin B6
Correct Answer: D
Rationale: Vitamin B6 (pyridoxine) aids in homocysteine metabolism, reducing blood levels. Other vitamins listed do not have this effect.