Nokea
A nurse is assessing a newborn who is 1 hour old. Which of the following findings should be reported to the healthcare provider? (Select all that apply)
- A. Respiratory rate of 50 breaths per minute
- B. Nasal flaring
- C. Grunting
- D. Temperature of 36.5°C (97.7°F)
Correct Answer: B,C
Rationale: Nasal flaring and grunting indicate respiratory distress, requiring immediate reporting. A respiratory rate of 50 and temperature of 36.5°C are normal for a newborn.
You may also like to solve these questions
An adult is scheduled for a cardioversion next week. What should the nurse plan to include when teaching the client about the procedure?
- A. The client should be NPO for eight hours before the procedure.
- B. The client will be awake during the procedure.
- C. The procedure will probably need to be repeated every month for at least six months.
- D. The procedure is usually done for life-threatening dysrhythmias such as ventricular fibrillation.
Correct Answer: A
Rationale: Cardioversion requires sedation, so the client must be NPO for 8 hours to prevent aspiration. The client is sedated, not awake, it's not typically repeated monthly, and it's used for atrial arrhythmias, not ventricular fibrillation.
A postoperative client is to be discharged today. She will need to change her dressing daily. Which statement she makes indicates that she understands the process?
- A. I will wash my hands before and after I change the dressing.'
- B. I can touch the dressings with my hands if I only touch the edges.'
- C. I should clean the area around the incision by moving the swab toward it.'
- D. I can put the old dressings directly in the waste basket.'
Correct Answer: A
Rationale: Hand washing before and after dressing changes prevents infection, reflecting proper understanding. Touching dressings, cleaning toward the incision, or improper disposal increase infection risk.
A client has been admitted in septic shock. Her nursing care plan includes the diagnosis High Risk for Injury (related to clotting disorder). Based on this diagnosis, all the following are appropriate entries in the nursing care plan except:
- A. obtain an order for a stool softener.
- B. administer packed RBCs, if ordered.
- C. encourage the client to rinse her mouth with mouthwash and scrub her teeth with an oral sponge.
- D. dress venipuncture sites immediately to prevent infection.
Correct Answer: D
Rationale: Firm, direct pressure should be applied to venipuncture sites for 3-7 minutes before final dressing because of the clotting abnormality.
A client with dumping syndrome should ___ while a client with GERD should ___
- A. sit up 1 hour after meals; lie flat 30 minutes after meals
- B. lie down 1 hour after eating; sit up at least 30 minutes after eating
- C. sit up after meals; sit up after meals
- D. lie down after meals; lie down after meals
Correct Answer: B
Rationale: Lying down after eating slows gastric emptying, reducing dumping syndrome symptoms. Sitting up prevents acid reflux in GERD. The other combinations are incorrect for these conditions. Basic Care and Comfort
Prochlorperazine maleate (Compazine) 10 mg IM has been ordered for a client. The client is also to receive Stadol 2 mg IM. Before administering these medications, the nurse should
- A. obtain respirations and temperature.
- B. dilute with 9 ml of NS.
- C. draw the medications in separate syringes.
- D. verify the route of administration.
Correct Answer: C
Rationale: Compazine (prochlorperazine) is incompatible with most medications, including Stadol (butorphanol), in the same syringe, as mixing may cause precipitation or reduced efficacy. Drawing them in separate syringes ensures safe administration. Monitoring vital signs (A) is less critical, dilution (B) is inappropriate, and verifying the route (D) is unnecessary as IM is specified.