Nokea
A nurse is providing teaching to parents of a newborn about genetic screening. Which of the following statements should the nurse include in the teaching?
- A. You should keep your baby's identification band on at all times.
- B. It is safe to leave your baby unattended in the room.
- C. Identification bands should be applied immediately after birth.
- D. Avoid public announcements about your baby's birth.
Correct Answer: D
Rationale: The correct answer is D because avoiding public announcements about the baby's birth is crucial to reduce the risk of newborn abduction. Public announcements can attract unwanted attention and potentially jeopardize the safety of the newborn. Choices A, B, and C are incorrect. Choice A is incorrect because the baby's identification band should be kept on at all times for security purposes. Choice B is incorrect because leaving the baby unattended in the room can pose risks. Choice C is incorrect because identification bands are usually applied immediately after birth, not after the first bath.
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A nurse is caring for a client with heart failure receiving digoxin. Which of the following findings should the nurse report to the provider?
- A. Heart rate 60/min.
- B. Blood pressure 110/70 mm Hg.
- C. Serum potassium 4 mEq/L.
- D. Blood pressure 120/80 mm Hg.
Correct Answer: B
Rationale: The correct answer is B. A blood pressure of 110/70 mm Hg is a finding that the nurse should report to the provider when caring for a client with heart failure receiving digoxin. Digoxin can cause hypotension, so a low blood pressure reading should be reported promptly to the provider for further evaluation and management. Choices A, C, and D are within normal ranges and would not require immediate reporting. A heart rate of 60/min is considered normal, but any further decrease should be monitored. A serum potassium level of 4 mEq/L is also within the normal range. A blood pressure of 120/80 mm Hg is typically considered normal as well.
A nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive disorder. Which of the following interventions should the nurse take?
- A. Allow the client enough time to perform rituals
- B. Give the client autonomy in scheduling activities
- C. Discourage the client from exploring irrational fears
- D. Provide negative reinforcement for ritualistic behaviors
Correct Answer: A
Rationale: The correct intervention for a client with obsessive-compulsive disorder is to allow the client enough time to perform rituals. This helps manage anxiety and stress in individuals with OCD. Allowing time for rituals can provide a sense of control and reduce distress. Choice B, giving the client autonomy in scheduling activities, may not address the core symptoms of OCD related to rituals and compulsions. Choice C, discouraging the client from exploring irrational fears, goes against the principles of exposure therapy, which is a common treatment for OCD. Choice D, providing negative reinforcement for ritualistic behaviors, is not recommended as it can reinforce the behavior rather than help the client manage it.
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 reviewing the medical record of a client with major depressive disorder who is taking fluoxetine. Which of the following findings should the nurse report to the provider?
- A. Heart rate of 80/min
- B. Blood pressure 130/80 mm Hg
- C. Weight gain of 2.2 kg (5 lb) in 1 week
- D. Temperature of 37.2°C (99°F)
Correct Answer: C
Rationale: The correct answer is C. A weight gain of 2.2 kg (5 lb) in 1 week can indicate fluid retention, a serious side effect of fluoxetine that should be reported to the provider. Choices A, B, and D are within normal ranges and are not alarming findings that would require immediate reporting to the provider. A heart rate of 80/min, blood pressure of 130/80 mm Hg, and a temperature of 37.2°C (99°F) are all within normal limits and not typically concerning in a client taking fluoxetine.
A client with chronic kidney disease is receiving dietary teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?
- A. I will increase my intake of bananas.
- B. I will limit my intake of foods high in potassium.
- C. I will increase my intake of protein-rich foods.
- D. I will increase my intake of dairy products.
Correct Answer: B
Rationale: The correct answer is B. Limiting potassium-rich foods is crucial for clients with chronic kidney disease to prevent hyperkalemia, a common complication. Increasing intake of potassium-rich foods like bananas (choice A), protein-rich foods (choice C), or dairy products (choice D) can exacerbate hyperkalemia in these clients. Bananas, protein-rich foods, and dairy products are all high in potassium, which is detrimental for individuals with chronic kidney disease. Therefore, choices A, C, and D are incorrect.