Nokea
A pediatric nurse would be concerned by which of the following sets of vital signs?
- A. newborn: BP 70/50, RR 47, HR 135
- B. 12-month-old: BP 65/55, RR 50, HR 130
- C. 10-year-old: BP 110/70, RR 16, HR 89
- D. 13-year-old: BP 120/82, RR 15, HR 80
Correct Answer: B
Rationale: 12-month-old vitals (BP 65/55, RR 50, HR 130) show low BP (normal ~90/50) and high RR (normal 20-30), suggesting distress. Other options are age-appropriate.
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The nurse is teaching feeding protocol to the spouse of a client who experienced a severe stroke. Which statement by the spouse indicates a need for further explanation by the nurse?
- A. I will not let him use a straw.
- B. I will turn on the television during meals.
- C. Instead of whole pills, I will crush the pill and place it in custard.
- D. He will sit up for a half hour after eating.
Correct Answer: B
Rationale: Turning on the television during meals can distract the client, increasing the risk of aspiration, and requires further teaching. Other statements are appropriate.
A client with a fractured hip is being taught correct use of the walker. The nurse is aware that the correct use of the walker is achieved if the:
- A. Palms rest lightly on the handles
- B. Elbows are flexed 0°
- C. Client walks to the front of the walker
- D. Client carries the walker
Correct Answer: A
Rationale: Palms resting lightly on the handles ensures proper weight distribution and stability.
A client is recovering from a stroke and the nurse is doing range-of-motion exercises. Which movements should be included for ROM of the elbow on the weak side? Select all that apply.
- A. Abduction and adduction
- B. Hyperextension
- C. Supination and pronation
- D. Flexion and extension
- E. Rotation
Correct Answer: C,D
Rationale: Elbow ROM includes supination/pronation (C) and flexion/extension (D). Abduction/adduction (A), hyperextension (B), and rotation (E) are not applicable to the elbow joint.
The nurse is providing discharge teaching to a client newly diagnosed with heart failure. Which statement by the client indicates an understanding of the side effects of furosemide (Lasix)?
- A. I should eat bananas, dried dates, or peaches every day.
- B. I should check my heart rate before taking this medicine.
- C. I will avoid foods containing tyramine while on this medicine.
- D. I will not take the medicine when I have to go on a long car trip.
Correct Answer: A
Rationale: Furosemide can cause potassium loss; eating potassium-rich foods like bananas, dates, or peaches shows understanding of managing this side effect.
A 28-year-old woman pregnant with twins comes in for her prenatal appointment. She tells the nurse that she has two children at home (ages 4 years and 16 months), and she had one abortion 6 years ago when she was 8 weeks along in the pregnancy. The nurse charts
- A. gravida 4, para 2.
- B. gravida 4, para 3.
- C. gravida 5, para 2.
- D. gravida 5, para 3.
Correct Answer: C
Rationale: Gravida counts all pregnancies (2 children, 1 abortion, current twin pregnancy = 5). Para counts deliveries after 20 weeks (2 children = 2). Twins count as one delivery.