Nokea
A school-aged child informs the school nurse that his right knee 'doesn't feel right.' Which of the following actions should the nurse take FIRST?
- A. Instruct the child to extend the right leg.
- B. Put both of the child's legs through range-of-motion.
- C. Advise the child to soak the right knee in warm water.
- D. Compare the appearance of the right knee with the left knee.
Correct Answer: D
Rationale: Comparing knees assesses for swelling or deformity, the first step in physical assessment. Options A, B, and C risk exacerbating injury or are interventions before assessment.
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A newborn.
While performing a physical examination on a newborn, which of the following nursing assessments should be reported to the doctor?
- A. Head circumference of 40 cm.
- B. Chest circumference of 32 cm.
- C. Acrocyanosis and edema of the scalp.
- D. Heart rate 160 and respirations 40.
Correct Answer: A
Rationale: Strategy: Determine if the assessment is abnormal. (1) correct-average circumference of the head for a neonate ranges from 32 to 36 cm; increase in size may indicate hydrocephaly or increased intracranial pressure (2) normal newborn assessment (3) normal newborn assessment (4) normal newborn assessment
A patient has a Levin tube connected to intermittent low suction. At 7 AM, the nurse charts that there is 235 cc of greenish drainage in the suction container. At 3 PM, the nurse notes that there is 445 cc of greenish drainage in the suction container. Twice during the shift, the nurse irrigates the Levin tube with 30 cc of normal saline, as ordered by the physician. What is the actual amount of drainage from the nasogastric tube for the 7 to 3 shift?
- A. 150 cc.
- B. 210 cc.
- C. 295 cc.
- D. 385 cc.
Correct Answer: A
Rationale: 445-235=210-60=150
A woman is in active labor with her first child when her membranes rupture. She voices a concern to the nurse that she is afraid of having a 'dry labor.' Which of the following responses by the nurse would be MOST appropriate?
- A. The amniotic fluid provides only minimal lubrication for the labor process.
- B. The amniotic sac may impede the progress of labor and is often ruptured artificially.
- C. Labor is only slightly more difficult with early rupture of the amniotic sac.
- D. Because there is limited amniotic fluid, additional fluids will be supplied.
Correct Answer: B
Rationale: Rupture of membranes can facilitate labor by removing the sac, which may impede progress, addressing the client’s 'dry labor' concern. Options A, C, and D are incorrect: amniotic fluid has multiple roles, labor difficulty is not significantly increased, and no fluids are added.
A client is currently hospitalized with renal failure and has 3+ pitting edema of the lower extremities.
Which of the following nursing observations would indicate a therapeutic response to therapy for the edema?
- A. Serum potassium 4.0 mEq/L.
- B. Plasma glucose 140 mg/dL.
- C. Increased specific gravity of the urine.
- D. Weight loss of 5 lb over last two days.
Correct Answer: D
Rationale: Strategy: Determine how each answer choice relates to edema. (1) no relation to edema (2) no relation to edema (3) urine specific gravity may be decreased as client begins to lose some edema fluid (4) correct-edema is a result of sodium and fluid retention; weight loss should occur if therapy is effective
A woman is in the clinic complaining of urinary frequency, urgency, and pain on urination. Orders include a urine for culture and administration of sulfisoxazole (Gantrisin) and phenazopyridine (Pyridium.) Which action should the nurse take first?
- A. Obtain a clean catch urine from the client.
- B. Ask the client if she is allergic to sulfa drugs.
- C. Administer the sulfisoxazole (Gantrisin).
- D. Administer the phenazopyridine (Pyridium).
Correct Answer: B
Rationale: Checking for sulfa allergies is critical before administering sulfisoxazole, as allergies can cause severe reactions, prioritizing safety.