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A nurse is caring for a preschooler. Which of the following findings should the nurse report to the healthcare provider immediately? Which finding in a preschooler should the nurse report immediately?
- A. Platelet count.
- B. Emesis.
- C. Absolute neutrophil count.
- D. Loss of appetite.
Correct Answer: C
Rationale: The correct answer is C: Absolute neutrophil count. Neutrophils are key components of the immune system, and a low absolute neutrophil count can indicate an increased risk of infection. In preschoolers, any significant deviation from the normal range should be reported promptly to the healthcare provider to prevent serious complications. Platelet count (A) may indicate bleeding disorders but is not as urgent as a low neutrophil count. Emesis (B) and loss of appetite (D) are common in preschoolers and may not be immediate concerns unless persistent or severe. Reporting a low absolute neutrophil count is crucial for timely intervention and management.
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A nurse is assisting a healthcare provider with a sterile procedure and is preparing to pour solution onto a sterile piece of gauze. In what sequence should the nurse perform the following steps when pouring the sterile solution? In what sequence should the nurse pour sterile solution?
- A. Pick up the bottle with the label facing the palm.
- B. Pour the solution onto the gauze.
- C. Pour 1 to 2 mL into a receptacle.
- D. Perform hand hygiene.
- E. Place the bottle cap face-up on a clean surface.
- F. Remove the bottle cap.
Correct Answer: D,A,F,C,E,B
Rationale: The correct sequence is D, A, F, C, E, B.
1. Perform hand hygiene to ensure cleanliness.
2. Pick up the bottle with the label facing the palm to maintain sterility.
3. Remove the bottle cap to prepare for pouring.
4. Pour 1 to 2 mL into a receptacle to ensure proper amount.
5. Place the bottle cap face-up on a clean surface to prevent contamination.
6. Pour the solution onto the gauze for the sterile procedure to be completed.
Incorrect choices:
- G: It is not a step in the process of pouring sterile solution.
- The correct order ensures sterility, proper amount, and prevention of contamination.
A nurse is educating a patient with diabetes who has been prescribed insulin glargine. What information should the nurse provide about this type of insulin?,What information should be provided about insulin glargine?
- A. Insulin glargine lasts for 3 to 6 hours.
- B. Insulin glargine lasts for 18 to 24 hours.
- C. Insulin glargine lasts for 16 to 24 hours.
- D. Insulin glargine lasts for 6 to 10 hours.
Correct Answer: B,C
Rationale: The correct answer is B and C. Insulin glargine is a long-acting insulin that provides a basal level of insulin over an extended period. Option B states that it lasts for 18 to 24 hours, which is accurate as it mimics the body's natural basal insulin secretion. Option C also mentions 16 to 24 hours, which is within the range of the duration of action for insulin glargine. Option A stating 3 to 6 hours is incorrect as it does not reflect the long-acting nature of insulin glargine. Option D stating 6 to 10 hours is also incorrect as it underestimates the duration. It is important for the nurse to emphasize the prolonged action of insulin glargine to ensure proper understanding and management by the patient.
A nurse plans to leave her scheduled shift an hour early without permission or notification of the charge nurse. The patients in her assignment are stable. Which of the following legal torts applies to this situation? Which legal tort applies to leaving shift early without permission?
- A. Negligence
- B. Battery
- C. Slander
- D. Libel
Correct Answer: A
Rationale: The correct answer is A: Negligence. Leaving the shift early without permission constitutes negligence as it is a breach of the duty of care owed to the patients. The nurse has a legal responsibility to provide care for the patients until properly relieved. The other choices, Battery, Slander, and Libel, do not apply in this scenario. Battery involves intentional harmful or offensive contact without consent, Slander involves spoken defamation, and Libel involves written defamation. In this case, the nurse's actions do not align with the elements of these torts.
A nurse is caring for a patient who has a new prescription for metformin. Which of the following laboratory tests should the nurse monitor? Which lab test should the nurse monitor for metformin?
- A. Liver function tests
- B. Thyroid function tests
- C. Complete blood count
- D. Renal function tests
Correct Answer: D
Rationale: The correct answer is D: Renal function tests. Metformin is primarily excreted by the kidneys, so monitoring renal function tests like serum creatinine and estimated glomerular filtration rate (eGFR) is crucial to assess kidney function and prevent potential metformin-induced lactic acidosis. Monitoring liver function tests (A) is not essential for metformin therapy, as metformin is not metabolized by the liver. Thyroid function tests (B) are not directly affected by metformin. Complete blood count (C) is not typically monitored specifically for metformin therapy. Therefore, the most appropriate choice is D as it directly reflects metformin's clearance and potential for toxicity.
Medical History (0700 hrs)
• Gestational age: 42 weeks
• Delivery: Spontaneous vaginal birth
• Amniotic fluid: Dark brown-greenish color noted
• Apgar scores: 8 at 1 minute, 9 at 5 minutes
Vital Signs (0700 hrs)
• Axillary temperature: 36.9°C (98.4°F)
• Heart rate: 170/min
• Respiratory rate: 72/min
• Birth weight: 4025 gm (8 lb 14 oz) (Appropriate for Gestational Age)
Nurses' Notes (0700 hrs)
The newborn was placed on the birth parent's abdomen immediately following delivery. The mouth and nose were suctioned with a bulb syringe to clear secretions. The newborn was dried and stimulated, resulting in a strong cry. The newborn was moving all extremities with a flexed tone noted. Acrocyanosis was present. The newborn was alert and active. Respirations were rapid and shallow with occasional expiratory grunting. Fine crackles were auscultated throughout the lung fields. A small amount of green- stained vernix was present in skin folds. The newborn had fingernails stained green. Molding of the skull and generalized soft occipital swelling were noted.
A nurse is caring for a newborn who is 30 minutes old following a spontaneous vaginal birth. The birth parent noted dark brown- greenish amniotic fluid during labor. The newborn was delivered at 42 weeks gestation. Apgar scores were 8 at 1 minute and 9 at 5 minutes. Exhibits After reviewing the information in the newborn's medical record, which of the following complications should the nurse identify as posing the greatest risk? Drag one condition and one client finding to fill in each blank in the following sentence.The condition that poses the greatest risk to the newborn is ---------------- due to -------------------
- A. Meconium aspiration syndrome
- B. Color of amniotic fluid
- C. Jaundice
- D. cold streets
- E. Birth Weight
Correct Answer: A,B
Rationale: Action to Take: A, B; Potential Condition: A; Parameter to Monitor: C, E.
Rationale:
- Meconium aspiration syndrome (MAS) is the correct answer as newborns exposed to meconium in amniotic fluid are at risk for respiratory distress.
- The color of amniotic fluid (brown-green) indicates presence of meconium, which can lead to MAS.
- Monitoring jaundice (C) is important as newborns with MAS may develop complications affecting liver function.
- Monitoring birth weight (E) is crucial as MAS can impact the newborn's overall health and growth.
Summary of Incorrect Choices:
- Jaundice (C): Although important to monitor, it is not the greatest risk in this scenario.
- Cold stress (D): Not relevant to the information provided about the newborn.
- Birth weight (E): While important to monitor, it is not the greatest risk posed by the scenario.