Nokea
A practical nurse (PN) is assigned to care for a newborn with a neural tube defect. Which dressing, if applied by the PN, would need no further intervention by the charge nurse?
- A. Telfa dressing with antibiotic ointment
- B. Moist sterile nonadherent dressing
- C. Dry sterile dressing that is occlusive
- D. Sterile occlusive pressure dressing
Correct Answer: B
Rationale: Before surgical closure, the sac is prevented from drying by the application of a sterile, moist, nonadherent dressing over the defect. Dressings are changed frequently to keep them moist.
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Home Medications
Vital signs
Temperature 98.5 F (36.9 C)
Blood pressure 110/74 mm Hg
Heart rate 68/min
Respirations 16/min
SpO2 97% on room air
Medication Prescription
Medication prescription
Clopidogrel: 75 mg PO, daily
Metoprolol XL: 50 mg PO, daily
Furosemide: 40 mg PO, twice daily
Fish oil: 4 g PO, daily
Intake and Output Record
Intake and output record
Time Oral Intake Output
0700 200 mL
0800 125 mL
1000 100 mL 250 mL
1200 200 mL 250 mL
1500 150 mL 375 mL
The nurse is caring for a client with coronary artery disease and heart failure. Which of the following findings would require immediate follow-up?
- A. bruises easily on the arms
- B. reports chronic fatigue
- C. muscle cramps in the legs
- D. reports feeling depressed
Correct Answer: C
Rationale: Hypokalemia (serum potassium <3.5 mEq/L [<3.5 mmol/L]) is a common adverse effect of potassium-wasting diuretics (eg,furosemide) that may cause leg cramps, muscle weakness, or ECG changes. Unmanaged hypokalemia can lead to lethal cardiac dyshythmias (eg, ventricular fibrillation, torsades de pointes) and paralysis. Therefore, the nurse should immediately notify the health care provider of symptoms of hypokalemia
A woman comes into the labor suite stating that her water has broken and she is in labor. Which symptoms point to the possible presence of placenta previa?
- A. Sudden knife-like pain in the lower abdomen accompanied by profuse vaginal bleeding
- B. Dark red vaginal discharge that started after she saw the physician this morning
- C. Bright red painless vaginal bleeding
- D. A tender rigid uterine wall and abdomen with no vaginal bleeding evident
Correct Answer: C
Rationale: Placenta previa typically presents with bright red, painless vaginal bleeding due to the placenta covering the cervix, distinguishing it from abruptio placentae or other conditions.
What is the primary goal of family education?
- A. symptom reduction
- B. improved quality of life
- C. increased knowledge about mental illness
- D. improved caregiving skills
Correct Answer: B
Rationale: Improving quality of life is the primary goal of family education.
The afternoon following a thyroidectomy, the client experiences all of the following. Which one indicates to the nurse that the client is experiencing a serious complication?
- A. A sore throat
- B. Pain at the surgical site
- C. Temperature of 100.2°F
- D. Sudden hoarseness
Correct Answer: D
Rationale: Sudden hoarseness post-thyroidectomy may indicate vocal cord paralysis or hematoma compressing the airway, a serious complication requiring immediate attention. Sore throat, surgical pain, or mild fever are expected.
The nurse is collecting data from a client with a history of alcohol use disorder who had an emergency appendectomy 3 days ago. Which of the following findings would indicate that the client is experiencing delirium tremens? Select all that apply.
- A. Bradypnea
- B. Diaphoresis
- C. Hallucinations
- D. Lethargy
- E. Tachycardia
Correct Answer: B,C,E
Rationale: Delirium tremens presents with diaphoresis, hallucinations, and tachycardia due to autonomic hyperactivity. Bradypnea and lethargy are not typical; agitation is more common.