Nokea
A nurse is caring for a client who is postpartum, has a deep-vein thrombosis, and is receiving heparin therapy via subcutaneous injections. Which of the following actions should the nurse take?
- A. Request a prescription for PRN aspirin from the provider.
- B. Massage the injection site thoroughly following administration.
- C. Instruct the client that they cannot breastfeed while receiving heparin.
- D. Administer the injection in the client's abdomen.
Correct Answer: D
Rationale: The nurse should administer the injection in the abdomen, as this is a common site for subcutaneous heparin administration. Aspirin is contraindicated for clients on heparin due to increased bleeding risk.
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To decrease the incidence of sudden infant death syndrome (SIDS), the parents will position the newborn in a:
- A. Prone position
- B. Supine position
- C. Side-lying position
- D. Semi-fowler's position
Correct Answer: B
Rationale: The safest sleeping position for infants is on their back (supine position). This reduces the risk of sudden infant death syndrome (SIDS), as sleeping in other positions can increase the risk of airway obstruction.
Which of the following interventions is most appropriate for a client with hyperemesis gravidarum?
- A. Encourage high-calorie meals
- B. Administer intravenous fluids
- C. Provide frequent small meals
- D. Limit fluid intake
Correct Answer: B
Rationale: Hyperemesis gravidarum is severe, persistent nausea and vomiting during pregnancy that can lead to dehydration and electrolyte imbalances. The priority intervention is to administer intravenous fluids to maintain hydration.
A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings should the nurse report to the healthcare provider?
- A. Urinary output of 40 mL/hr
- B. Respiratory rate of 10 breaths per minute
- C. Absent deep tendon reflexes
- D. Blood pressure of 150/90 mm Hg
Correct Answer: B
Rationale: Magnesium sulfate can depress the central nervous system, leading to respiratory depression. A respiratory rate of 10 breaths per minute is below the normal range and requires immediate intervention.
A nurse is caring for a newborn diagnosed with necrotizing enterocolitis (NEC). Which of the following interventions should the nurse expect to implement?
- A. Administer oral feedings
- B. Measure abdominal girth
- C. Position the newborn prone
- D. Apply warm compresses to the abdomen
Correct Answer: B
Rationale: Measuring abdominal girth is important in monitoring for signs of abdominal distension, which is a key indicator of worsening necrotizing enterocolitis (NEC). Other interventions include withholding oral feedings and providing IV fluids or nutrition.
During a breast examination on a 24-year-old client the nurse notes the following findings. Which finding is of most concern and should be reported to the provider?
- A. An irregularly shaped, nontender lump is palpable in the right breast
- B. Tenderness is present during menstruation
- C. Bilateral, symmetrical lumps that move with palpation
- D. The client reports breast tenderness before menstruation
Correct Answer: A
Rationale: An irregularly shaped, nontender lump is a concerning finding because it may indicate breast cancer. The nurse should report this finding to the provider for further investigation.