Nokea
All of the following are parts of the middle ear EXCEPT the
- A. pinna.
- B. incus.
- C. stapes.
- D. malleus.
Correct Answer: A
Rationale: The middle ear includes the incus, stapes, and malleus (ossicles). The pinna is part of the outer ear.
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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.
An elderly client is diagnosed with ovarian cancer. She has surgery followed by chemotherapy with a fluorouracil (Adrucil) IV. What should the nurse do if she notices crystals in the IV medication?
- A. Discard the solution and order a new bag
- B. Warm the solution
- C. Continue the infusion and document the finding
- D. Discontinue the medication
Correct Answer: A
Rationale: Crystals in IV fluorouracil indicate precipitation; the solution should be discarded to prevent administration errors.
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.
A nurse creates a care plan for a client diagnosed with a cerebellar brain tumor. The correct nursing diagnosis for this client is 'Client at risk for injury related to
- A. impaired balance.'
- B. decreased visual acuity.'
- C. decreased level of consciousness.'
- D. impaired ability to make decisions.'
Correct Answer: A
Rationale: Cerebellar tumors impair coordination and balance, increasing fall risk, making 'impaired balance' the most relevant diagnosis.
Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?
- A. Oral mucous membrane, altered related to chemotherapy
- B. Risk for injury related to thrombocytopenia
- C. Fatigue related to the disease process
- D. Interrupted family processes related to life-threatening illness of a family member
Correct Answer: B
Rationale: Thrombocytopenia in acute leukemia increases the risk of bleeding, making 'risk for injury' the priority diagnosis to ensure patient safety.