Nokea
A nurse is caring for a 1-day-old newborn who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take?
- A. Feed the infant 30 ml (1 oz) of glucose water every 2 hours.
- B. Keep the infant's head uncovered.
- C. Ensure that the newborn wears a diaper.
- D. Apply lotion to the newborn every 4 hours.
Correct Answer: C
Rationale: The correct action for the nurse to take is to ensure that the newborn wears a diaper. This is important to prevent irritation during phototherapy, as exposure to light can increase the risk of skin breakdown. Feeding the infant glucose water is unnecessary and not indicated for jaundice treatment. Keeping the infant's head uncovered allows the light to reach the skin effectively. Applying lotion to the newborn every 4 hours can interfere with the effectiveness of phototherapy and is not recommended.
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A nurse is reviewing the laboratory report of a client who has been receiving lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect?
- A. Withhold the next dose.
- B. Increase the dosage.
- C. Discontinue the medication.
- D. Administer the medication.
Correct Answer: D
Rationale: Administering the medication is appropriate for a stable lithium level of 0.8 mEq/L. A level of 0.8 mEq/L falls within the therapeutic range for lithium, indicating that the client is receiving an adequate dose to maintain therapeutic effects. Withholding the next dose, increasing the dosage, or discontinuing the medication would not be indicated at this lithium level as it is within the desired range for therapeutic benefit. Therefore, the correct action would be to continue administering the medication to ensure the client maintains the therapeutic level of lithium.
A client in active labor has ruptured membranes. What action should the nurse take?
- A. Apply a fetal heart rate monitor.
- B. Initiate fundal massage.
- C. Administer oxytocin IV.
- D. Insert an indwelling urinary catheter.
Correct Answer: A
Rationale: When a client in active labor has ruptured membranes, the priority action for the nurse is to apply a fetal heart rate monitor. This is crucial for continuous monitoring of the baby's heart rate and ensuring fetal well-being. Initiating fundal massage may be indicated for uterine atony after delivery, not for ruptured membranes during labor. Administering oxytocin IV could be appropriate in some cases to augment labor, but it is not the immediate priority after ruptured membranes. Inserting an indwelling urinary catheter is not necessary solely based on ruptured membranes; it may be indicated for specific situations like epidural anesthesia where the client cannot void.
A nurse is teaching a client who has hypertension about managing blood pressure. Which of the following statements should the nurse make?
- A. Increase your intake of red meat to manage your blood pressure.
- B. You should avoid drinking alcohol while taking this medication.
- C. Exercise for at least 30 minutes most days of the week.
- D. Limit your fluid intake to 3 liters per day.
Correct Answer: C
Rationale: The correct statement is C: 'Exercise for at least 30 minutes most days of the week.' Regular exercise is essential in managing blood pressure as it helps improve cardiovascular health. Choice A is incorrect as increasing red meat intake can be detrimental due to its high saturated fat content, which can negatively impact blood pressure. Choice B is not directly related to managing blood pressure unless the medication interacts negatively with alcohol. Choice D, limiting fluid intake to 3 liters per day, is not a general recommendation for managing blood pressure unless specifically advised by a healthcare provider.
A nurse is caring for a client who has experienced a stroke and has aphasia. Which of the following communication strategies should the nurse use?
- A. Speak louder to help the client understand
- B. Speak using simple sentences and gestures
- C. Use a picture board to facilitate communication
- D. Have the client practice writing words down
Correct Answer: C
Rationale: The correct answer is to use a picture board to facilitate communication. Aphasia can make it challenging for individuals to understand and use language. Using a picture board can help the client convey their needs and understand information more effectively. Speaking louder (A) may not be helpful as aphasia is not related to hearing loss. While speaking using simple sentences and gestures (B) can be beneficial, using a picture board (C) is a more concrete and visual method to support communication for individuals with aphasia. Having the client practice writing words down (D) may not be suitable if the client's expressive language skills are impaired due to aphasia.
A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets. After securing the client's airway and initiating an IV, which of the following actions should the nurse take next?
- A. Monitor the client's IV site for thrombophlebitis
- B. Administer flumazenil to the client
- C. Evaluate the client for further suicidal behavior
- D. Initiate seizure precautions for the client
Correct Answer: B
Rationale: In cases of benzodiazepine overdose, such as diazepam ingestion, flumazenil is the antidote. Therefore, the priority action for the nurse is to administer flumazenil to the client. Monitoring the IV site for thrombophlebitis (Choice A) is important but not the immediate priority. Evaluating the client for further suicidal behavior (Choice C) is important but not the next immediate action. Initiating seizure precautions (Choice D) is not the priority as the client's airway has already been secured.