Nokea
A nurse is assessing for jaundice in a dark-skinned newborn. Where is the best place to assess for jaundice in this newborn?
- A. Buttocks
- B. Tip of nose and sclera
- C. Sclera, conjunctiva, and oral mucosa
- D. Palms of hands and soles of feet
Correct Answer: C
Rationale: The best place to assess for jaundice in a dark-skinned newborn is in the sclera, conjunctiva, and oral mucosa. Jaundice, which is caused by elevated levels of bilirubin in the blood, is more easily seen in these areas compared to the skin. While jaundice is commonly assessed on the skin in light-skinned individuals, it may not be as readily apparent in dark-skinned newborns. Therefore, examining the sclera, conjunctiva, and oral mucosa for a yellowish discoloration provides a more reliable indication of jaundice in dark-skinned infants. This approach ensures that healthcare providers can accurately detect and monitor jaundice in newborns of all skin tones.
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Which of the ff values pertaining to different clients shows the normal range of plasma pH?
- A. 7.35-7.45
- B. 8-Jul
- C. 6.35-6.45
- D. 8.35-8.45
Correct Answer: A
Rationale: The normal range of plasma pH in the human body typically falls between 7.35 and 7.45. This range is necessary to maintain the body's acid-base balance, which is crucial for normal physiological functioning. Deviations from this range can indicate acidosis (pH < 7.35) or alkalosis (pH > 7.45), both of which can have serious health implications. Therefore, option A (7.35-7.45) represents the normal range of plasma pH among different clients.
As part of the treatment for heart failure, the child takes the diuretic furosemide (Lasix). As part of teaching home care, the nurse encourages the family to give the child foods such as bananas, oranges, and leafy vegetables. These foods are recommended because they are high in which nutrient?
- A. Chlorides
- B. Potassium
- C. Sodium
- D. Vitamins
Correct Answer: B
Rationale: The diuretic furosemide (Lasix) can cause the loss of potassium in the body through increased urination. Potassium is an important mineral that helps maintain normal heart function. Therefore, it is essential to consume foods rich in potassium, such as bananas, oranges, and leafy vegetables, to prevent potassium deficiency (hypokalemia) and support heart health, especially in individuals taking diuretics for conditions like heart failure.
For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the plan of care?
- A. Administering aspirin if the temperature exceeds 102â—‹1 F (38.8â—‹0 C)
- B. inspecting the skin for petechiae once every shift
- C. providing for frequent rest periods
- D. Placing the client in strict isolation
Correct Answer: C
Rationale: Providing for frequent rest periods is the most appropriate intervention for a client newly diagnosed with radiation-induced thrombocytopenia. Thrombocytopenia is characterized by a decreased number of platelets, which are essential for blood clotting. Clients with thrombocytopenia are at an increased risk for bleeding and bruising. Therefore, it is important to prevent activities that may lead to injury or bleeding. Providing frequent rest periods allows the client to conserve energy and minimize the risk of trauma that could lead to bleeding complications. This intervention helps manage the symptoms associated with thrombocytopenia and promotes the client's safety and well-being.
By the age of 7 months, the infant is able to do all the following EXCEPT
- A. transfer object from hand to hand
- B. actively bounces
- C. uses radial palm grasp
- D. cruises
Correct Answer: D
Rationale: Cruising typically occurs later, around 9-10 months.
The twelve-year-old boy has fractured his arm because of a fall from his bike. After the injury has been casted, the nurse knows it is most important to perform all of the following assessments on the area distal to the injury except:
- A. capillary refill.
- B. radial and ulnar pulse.
- C. finger movement
- D. skin integrity
Correct Answer: B
Rationale: Assessing the radial and ulnar pulses is crucial in evaluating the circulation of blood to the hand. However, in this scenario of a fractured arm, the injury is distal to the hand (further away from the body). It is more critical to check capillary refill, finger movement, and skin integrity in the area distal to the injury to ensure there is no compromise to the blood flow, nerve function, or skin integrity following the injury. Checking the radial and ulnar pulse would be more relevant if the injury was closer to the wrist area, as it would directly impact these pulses.