Nokea
A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take?
- A. Obtain the newborn's body temperature using a tympanic thermometer
- B. Pull the pinna of the infant's ear forward before inserting the probe
- C. Auscultate the newborn's apical pulse for 60 seconds
- D. Measure the newborn's head circumference over the eyebrows and below the occipital prominence
Correct Answer: C
Rationale: The correct answer is C: Auscultate the newborn's apical pulse for 60 seconds. When assessing a newborn, it is essential to auscultate the apical pulse for a full 60 seconds to accurately determine their heart rate. This method allows for a more precise measurement, considering the variability in heart rates in newborns. Choice A is incorrect because tympanic thermometers are not typically used for newborns due to their ear canals being small and not fully developed. Choice B is incorrect as pulling the pinna forward is not necessary for assessing the apical pulse. Choice D is incorrect as measuring head circumference involves a different assessment and is not relevant to determining the heart rate of a newborn.
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A nurse is assessing a client who has just returned from surgery and is experiencing acute pain. Which of the following findings should the nurse expect?
- A. Bradycardia.
- B. Hypotension.
- C. Diaphoresis.
- D. Hyperactive bowel sounds.
Correct Answer: C
Rationale: The correct answer is C: Diaphoresis. Diaphoresis, which is excessive sweating, is a common response to acute pain due to increased sympathetic nervous system activity. Options A and B, Bradycardia and Hypotension, are unlikely findings in a client experiencing acute pain as pain usually triggers an increase in heart rate (tachycardia) and blood pressure. Option D, Hyperactive bowel sounds, is not typically associated with acute pain.
A client who is at 36 weeks of gestation is scheduled for a nonstress test (NST). Which of the following statements by the client indicates an understanding of the teaching?
- A. I should fast for 12 hours before the test.
- B. I should expect the test to take about 10 minutes.
- C. I should have a full bladder for this test.
- D. I will need to have my blood glucose checked before the test.
Correct Answer: B
Rationale: The correct answer is B. The nonstress test typically takes about 10 minutes and evaluates the fetal heart rate in response to fetal movement. Having a full bladder or fasting for 12 hours is not required for a nonstress test. Checking blood glucose levels is not part of the nonstress test procedure.
A nurse is preparing to teach a client about the use of a peak flow meter. Which of the following instructions should the nurse include?
- A. Place the mouthpiece in your mouth and blow out as quickly as you can.
- B. Exhale slowly into the mouthpiece over 5 seconds.
- C. Take a slow deep breath before blowing into the mouthpiece.
- D. Blow into the mouthpiece at a steady rate for 3 seconds.
Correct Answer: A
Rationale: The correct instruction for using a peak flow meter is to place the mouthpiece in your mouth and blow out as quickly as you can. This action helps measure the peak expiratory flow of the client. Choice B is incorrect because exhaling slowly does not provide an accurate peak flow reading. Choice C is incorrect as taking a slow deep breath before blowing interferes with obtaining an accurate measurement. Choice D is incorrect as blowing at a steady rate for 3 seconds may not reflect the peak expiratory flow accurately.
A client who has a new prescription for lisinopril is being taught by a nurse. Which of the following client statements indicates an understanding of the teaching?
- A. I should avoid using salt substitutes while taking this medication.
- B. I should take this medication with food to prevent nausea.
- C. I should increase my intake of potassium-rich foods while taking this medication.
- D. I should limit my fluid intake while taking this medication.
Correct Answer: A
Rationale: The correct answer is A. Lisinopril can increase potassium levels, so clients should avoid salt substitutes that contain potassium. Choice B is incorrect because lisinopril is usually taken on an empty stomach. Choice C is incorrect because lisinopril can lead to hyperkalemia, so increasing potassium-rich foods is not recommended. Choice D is incorrect because lisinopril can cause increased urination, so fluid intake should not be limited.
A client with schizophrenia is pacing the hall and is agitated. Which of the following actions should the nurse take?
- A. Ask the client if they intend to harm others.
- B. Tell the client to stop pacing the hall.
- C. Allow the client to pace alone until they feel less anxious.
- D. Walk with the client at a gradually slower pace.
Correct Answer: D
Rationale: The correct action for the nurse to take when caring for a client with schizophrenia who is pacing the hall and agitated is to walk with the client at a gradually slower pace. This approach can help reduce the client's agitation and prevent the situation from escalating. Choice A is incorrect because directly asking about harm may increase the client's anxiety. Choice B is inappropriate as it may worsen the client's agitation. Choice C is not recommended as the client may benefit from the nurse's presence and support during this time of distress.