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.
You may also like to solve these questions
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 nurse is teaching a newly licensed nurse about using a portable oxygen system. What instruction should the nurse include?
- A. The oxygen should be kept in a storage room when not in use.
- B. Turn off the oxygen when not in use.
- C. Check the oxygen level regularly using a pulse oximeter.
- D. Never leave the oxygen running when transporting a client.
Correct Answer: C
Rationale: The correct answer is to check the oxygen level regularly using a pulse oximeter. This instruction is crucial as it ensures safe and adequate oxygenation for the client. Option A is incorrect as oxygen should not be stored in a storage room but in a well-ventilated area. Option B is not ideal as oxygen should be left on unless otherwise specified by a healthcare provider. Option D is also important but not directly related to the primary instruction of monitoring oxygen levels.
A nurse is caring for a client who has end-stage kidney disease. The client's adult child asks the nurse about becoming a living kidney donor for her father. Which of the following conditions in the child's medical history should the nurse identify as a contraindication to the procedure?
- A. Amputation.
- B. Osteoarthritis.
- C. Hypertension.
- D. Primary glaucoma.
Correct Answer: C
Rationale: Hypertension is a contraindication for kidney donation because it can negatively impact the donor's health in the long term. Hypertension poses risks during and after the donation procedure, such as affecting kidney function and potentially leading to complications for both the donor and the recipient. Amputation, osteoarthritis, and primary glaucoma are not direct contraindications for kidney donation and would not typically prevent someone from being a living kidney donor.
A nurse is assessing a client who has a chest tube. Which of the following findings should the nurse report to the provider?
- A. Constant bubbling in the water seal chamber.
- B. Intermittent bubbling in the suction control chamber.
- C. Tidaling in the water seal chamber.
- D. Drainage of 75 mL in the first 24 hours.
Correct Answer: A
Rationale: The correct answer is A: Constant bubbling in the water seal chamber. Constant bubbling in the water seal chamber can indicate an air leak, which compromises the integrity of the chest tube system and should be reported to the provider for immediate intervention. Choices B, C, and D are incorrect. Intermittent bubbling in the suction control chamber is an expected finding indicating that the system is working appropriately. Tidaling in the water seal chamber is a normal fluctuation of fluid level with inspiration and expiration, indicating that the system is functioning correctly. Drainage of 75 mL in the first 24 hours is within the expected range for chest tube drainage and does not require immediate reporting unless accompanied by other concerning symptoms.
A client who has a new prescription for prednisone is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will avoid taking this medication with food.
- B. I will need to take this medication for the rest of my life.
- C. I will take this medication for 2 weeks and then stop.
- D. I will take this medication with a high-protein snack.
Correct Answer: B
Rationale: The correct answer is B because prednisone is usually prescribed for long-term use. Stopping it abruptly can lead to adrenal insufficiency. Choice A is incorrect because prednisone should be taken with food to prevent stomach upset. Choice C is incorrect as prednisone is typically tapered off gradually to avoid adverse effects. Choice D is incorrect as there is no specific requirement to take prednisone with a high-protein snack.