Nokea
A woman brings her 6-month-old daughter to a clinic for a checkup and immunizations. The mother tells the nurse that her infant is cranky, has a bad cold, and has not eaten well the last days. She asks if the baby will still be able to get her shots. The child's temperature is 100.8°F. How should the nurse respond?
- A. There is no problem in giving the shots just because your baby has a cold.'
- B. Your baby will have her checkup, but we will wait until her cold is better before giving her shots.'
- C. The shots often make them a little irritable, so we might as well get it all over with at one time.'
- D. I'm not sure why you came today. We need to reschedule the whole appointment for another day when your baby has no symptoms of a cold.'
Correct Answer: B
Rationale: Mild fever and illness contraindicate vaccinations due to potential reduced immune response and difficulty distinguishing vaccine reactions from illness symptoms.
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The nurse is caring for a newborn. Which of the following signs would indicate neonatal abstinence syndrome? Select all that apply.
- A. Irritability and restlessness
- B. Meconium ileus and floppy muscle tone
- C. Microcephaly and cleft palate
- D. Nasal congestion and frequent sneezing
- E. Poor feeding and loose stools
Correct Answer: A,D,E
Rationale: Neonatal abstinence syndrome includes irritability , nasal congestion and sneezing , and poor feeding with loose stools due to withdrawal. Meconium ileus and hypotonia suggest cystic fibrosis, and microcephaly and cleft palate are congenital anomalies.
A woman is being seen in the physician's office for a medical complaint. When she is called to see the physician, she goes to the restroom and washes her hands over and over, missing her allotted time with the physician. How should the nurse deal with this woman?
- A. Send her home without seeing the doctor if she is not available when called
- B. Give her advance warning that she will be seeing the physician and tell her that if she needs to wash her hands, she should do so
- C. Interrupt her washing ritual and insist that she see the physician when it is her turn
- D. Give her a choice of seeing the physician or washing her hands
Correct Answer: B
Rationale: Advance warning accommodates possible OCD, allowing hand washing within a timeframe, ensuring she sees the physician. Sending home, interrupting, or forcing choices is less effective.
The client has been receiving garamycin 65 mg IVPB every 8 hours for the past 6 days. Which lab result indicates an adverse reaction to the medication?
- A. WBC 7500
- B. Serum glucose 92
- C. Protein 3.5
- D. Serum Creatinine 2.0
Correct Answer: D
Rationale: Garamycin (gentamicin) is an aminoglycoside antibiotic that can cause nephrotoxicity. A serum creatinine level of 2.0 mg/dL is elevated (normal range is approximately 0.6-1.2 mg/dL), indicating potential kidney damage, an adverse reaction. Answers A, B, and C represent normal or unrelated lab values.
A nurse is participating in an obstetrical emergency simulation in which the health care provider announces shoulder dystocia. Which of the following interventions should the assisting nurse implement? Select all that apply.
- A. Perform fundal massage
- B. Document the exact time of events
- C. Flex the client's legs back against the abdomen
- D. Request immediate assistance from other nurses
- E. Apply downward pressure above the client's symphysis pubis
Correct Answer: B,C,D,E
Rationale: For shoulder dystocia: document timing for accuracy, flex legs for McRoberts maneuver, request help for additional support, and apply suprapubic pressure to dislodge the shoulder. Fundal massage is for postpartum hemorrhage.
The postoperative client on hydrocodone becomes hypoxic, and naloxone is administered per protocol. What is most important for the nurse to consider in the follow-up care of this client?
- A. Client's respiratory status 60 minutes later
- B. Documenting the client's hypoxic event
- C. Obtaining an order for a different analgesic
- D. Potential for drug-drug interaction now
Correct Answer: A
Rationale: After naloxone administration for opioid-induced hypoxia, monitoring respiratory status is critical as naloxone's effects are short-acting, and respiratory depression may recur. Documentation is important but secondary, changing analgesics is not immediate, and drug interactions are less urgent.