Nokea
A nurse performing a newborn assessment would expect what respiratory rate and heart rate as a normal finding?
- A. RR 15 breaths/minute, HR 72 beats/minute
- B. RR 35 breaths/minute, HR 96 beats/minute
- C. RR 46 breaths/minute, HR 153 beats/minute
- D. RR 68 breaths/minute, HR 137 beats/minute
Correct Answer: C
Rationale: Newborns have a respiratory rate of 30-60 breaths/min and heart rate of 120-160 beats/min. Option C (RR 46, HR 153) is within normal ranges.
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An obstetric client is admitted with dehydration. Which IV fluid would be most appropriate for the client?
- A. .45 normal saline
- B. Dextrose 1% in water
- C. Lactated Ringer's
- D. Dextrose 5% in .45 normal saline
Correct Answer: C
Rationale: Lactated Ringer's is isotonic and effective for correcting dehydration in obstetric clients, replacing fluids and electrolytes.
A 52-year-old client is undergoing menopause. Which of the following physical sign or symptom is often attributed to decreased estrogen production associated with menopause?
- A. Weight loss
- B. Excessive sleeping
- C. Increased fat deposits on hips and abdomen
- D. Increased metabolic rate
Correct Answer: C
Rationale: Decreased estrogen in menopause often leads to increased fat deposits on hips and abdomen (C). Weight loss (A), excessive sleeping (B), and increased metabolic rate (D) are not typical.
The registered nurse is conducting an in-service for colleagues on the subject of peptic ulcers. The nurse would be correct in identifying which of the following as a causative factor?
- A. N. gonorrhea
- B. H. influenza
- C. H. pylori
- D. E. coli
Correct Answer: C
Rationale: H. pylori is a primary causative factor in peptic ulcers, contributing to mucosal damage and ulcer formation.
A client with a C3 spinal cord injury experiences autonomic hyperreflexia. After placing the client in high Fowler's position, the nurse's next action should be to:
- A. Notify the physician
- B. Make sure the catheter is patent
- C. Administer an antihypertensive
- D. Provide supplemental oxygen
Correct Answer: B
Rationale: Autonomic hyperreflexia is often triggered by bladder distension; ensuring a patent catheter addresses the most common cause and can resolve symptoms.
The nurse is preparing to deliver an infusion of vancomycin through a client's peripherally inserted central catheter (PICC). Shortly after the infusion begins the IV pumps beeps, indicating a blockage. How should the nurse proceed? Select all that apply.
- A. start a peripheral IV in the opposite limb
- B. notify the PICC nurse if unable to clear the blockage
- C. use a 5 mL syringe to flush the PICC with sterile saline
- D. ask the client to raise and lower the arm or cough
- E. attempt to flush the line by aggressively pushing heparin to clear the blockage
- F. use a 10 mL syringe to gently flush the PICC with sterile saline or tPA as ordered
Correct Answer: B, D, F
Rationale: Notifying the PICC nurse, repositioning the arm, and gently flushing with a 10 mL syringe (saline or tPA as ordered) are appropriate. Aggressive flushing or small syringes risk damage, and a peripheral IV is unnecessary.