Nokea
An infant with increased intracranial pressure (ICP) on a regular diet vomits while eating dinner. Which of the following should the nurse do next?
- A. Put the child on nothing-by-mouth (NPO) status.
- B. Call to report this event to the physician.
- C. Wait a few minutes, then refeed the child.
- D. Administer the prescribed antiemetic.
Correct Answer: B
Rationale: Vomiting in an infant with increased ICP may indicate worsening pressure, requiring immediate physician notification.
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Which of the following data points about your client's hemodynamic values would you report to the doctor as abnormal?
- A. Pulmonary Artery Systolic Pressure: 22 mm Hg
- B. Pulmonary Artery Wedge Pressure: 22 mm Hg
- C. Pulmonary Artery Diastolic Pressure: 10 mm Hg
- D. Central Venous Pressure: 5 mm Hg
Correct Answer: B
Rationale: Normal ranges are: PAS 15-30 mmHg, PAWP 4-12 mmHg, PAD 4-12 mmHg, CVP 2-6 mmHg. PAWP of 22 mmHg is elevated, indicating potential left ventricular dysfunction or fluid overload.
A nulliparous client visiting the clinic tells the nurse that she stopped taking oral contraceptives 6 months ago but doesn't think she is ovulating. Which of the following should the nurse anticipate that the physician would order if the client is anovulatory?
- A. Denestrol (Ortho Dienestrol)
- B. Clomiphene citrate (Clomid)
- C. Medroxyprogesterone (Depo-Provera)
- D. Norgestrel (Ovrette)
Correct Answer: B
Rationale: Clomiphene citrate is commonly prescribed to stimulate ovulation in anovulatory clients. Denestrol is an estrogen, medroxyprogesterone is a progestin for contraception or other uses, and norgestrel is a contraceptive, not for inducing ovulation.
A new breast-feeding mother experiencing breast engorgement is provided with instructions regarding care for the condition. Which statement by the mother indicates to the nurse that she possesses an understanding of the measures that will provide comfort for the engorgement?
- A. I will breast-feed using only one breast.
- B. I will apply cold compresses to my breasts.
- C. I will avoid the use of a bra while my breasts are engorged.
- D. I will massage my breasts before feeding to stimulate letdown.
Correct Answer: D
Rationale: Comfort measures for breast engorgement include massaging the breasts before feeding to stimulate letdown, alternating the breasts during feeding, taking a warm shower or applying warm compresses just before feeding, and wearing a supportive well-fitting bra at all times. None of the other options suggest correct measures.
The nurse is preparing a teaching plan for a 45-year-old client recently diagnosed with type 2 diabetes mellitus. What is the first step in this process?
- A. Establish goals.
- B. Assess the client's learning needs.
- C. Set priorities of learning needs.
- D. Select teaching strategies.
Correct Answer: B
Rationale: Assessing the client's learning needs is the first step to tailor education to their knowledge level, preferences, and barriers, ensuring effective teaching.
The nurse is preparing to administer a measles, mumps, and rubella (MMR) vaccine to a 15-month-old. Where should the nurse administer the injection?
- A. Deltoid muscle
- B. Vastus lateralis muscle
- C. Gluteal muscle
- D. Subcutaneous tissue of the abdomen
Correct Answer: B
Rationale: The vastus lateralis is the preferred site for intramuscular vaccines like MMR in toddlers due to adequate muscle mass and low risk of nerve damage.