Nokea
An 8.5 lb, 6 oz infant is delivered to a diabetic mother. Which nursing intervention would be implemented when the neonate becomes jittery and lethargic?
- A. Administer insulin
- B. Administer oxygen
- C. Feed the infant glucose water (10%)
- D. Place infant in a warmer
Correct Answer: C
Rationale: Jitteriness and lethargy suggest hypoglycemia, common in infants of diabetic mothers; glucose water corrects this.
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The most important nursing intervention to correct skin dryness is:
- A. Avoid bathing the patient until the condition is remedied, and notify the physician
- B. Ask the physician to refer the patient to a dermatologist, and suggest that the patient wear home-laundered sleepwear
- C. Consult the dietitian about increasing the patient's fat intake, and take necessary measures to prevent infection
- D. Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and apply lotion to the involved areas
Correct Answer: D
Rationale: Hydration, gentle soap, and lotion address dryness and prevent cracking.
Which of the following do not correctly correlates the increase BP of Ms. Aida, a 70 year old diabetic?
- A. Females, after the age 65 tends to have lower BP than males
- B. Disease process like Diabetes increase BP
- C. BP is highest in the morning, and lowest during the night
- D. Africans, have a greater risk of hypertension than Caucasian and Asians.
Correct Answer: A
Rationale: Females over 65 often have higher BP e.g., post-menopause not lower, contradicting Aida's rise. Diabetes (vessel damage), morning peaks (circadian), African risk (genetics) align. Nurses note this e.g., elderly diabetics for management.
When you discover an electrical fire and decide you need a fire extinguisher, you will need to find a fire extinguisher that is rated for which class of fire?
- A. Class A
- B. Class B
- C. Class C
- D. Class E
Correct Answer: C
Rationale: An electrical fire requires a Class C extinguisher, designed for energized electrical equipment like appliances or wiring. Class A suits ordinary combustibles (wood), Class B handles flammable liquids, and Class E isn't standard (often confused with electrical but not U.S.-classified). Using a Class C extinguisher, typically with non-conductive agents like carbon dioxide, ensures safety by avoiding shock while extinguishing. This choice protects both the nurse and client in a healthcare setting, aligning with fire safety protocols.
When giving a client a diagnosis of acute pain, the nurse 'using NANDA diagnostic categories' will use this diagnosis only when the pain last no longer than which of the following lengths of time?
- A. 3 days
- B. 2 weeks
- C. 1 month
- D. 6 months
Correct Answer: D
Rationale: NANDA defines acute pain as lasting up to 6 months, beyond which it's chronic. Nurses use this timeframe for diagnosis accuracy.
Which activity is an example of health promotion by the nurse
- A. Administering immunizations
- B. Giving a bedbath
- C. Preventing complications after an accident
- D. Performing diagnostic procedures
Correct Answer: A
Rationale: Health promotion enhances well-being and prevents disease proactively administering immunizations (e.g., measles vaccine) exemplifies this, boosting immunity before illness strikes. Giving a bedbath is hygiene, not promotion supportive, not preventive. Preventing complications post-accident is tertiary prevention, managing existing issues, not promoting health preemptively. Diagnostic procedures (e.g., blood tests) detect, not promote assessment, not prevention. Immunizations align with health promotion's focus on empowering clients against disease, a core nursing role in public health, making this the standout example.