Nokea
As a part of a 9 pound full-term newborn's assessment, the nurse performs a dextro-stick at 1 hour post birth. The serum glucose reading is 45 mg/dl. What action by the nurse is appropriate at this time?
- A. Give oral glucose water
- B. Notify the pediatrician
- C. Repeat the test in 2 hours
- D. Check the pulse oximetry reading
Correct Answer: C
Rationale: Repeat the test in 2 hours. This blood sugar is within the normal range for a full-term newborn. Normal values are: Premature infant: 20-60 mg/dl or 1.1-3.3 mmol/L, Neonate: 30-60 mg/dl or 1.7-3.3 mmol/L, Infant: 40-90 mg/dl or 2.2-5.0 mmol/L. Critical values are: Infant: <40 mg/dl and in a Newborn: <30 and >300 mg/dl. Because of the increased birth weight which can be associated with diabetes mellitus, repeated blood sugars will be drawn.
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The nurse is to start oxygen therapy via nasal cannula. Which action is correct?
- A. Set the oxygen at 12 L/min.
- B. Lubricate the cannula with petrolatum before inserting.
- C. Give 100% oxygen by mask before inserting.
- D. Insert the cannula 1 cm into the nostrils.
Correct Answer: D
Rationale: Inserting the cannula 1 cm into the nostrils ensures proper oxygen delivery. High flow rates, petrolatum, or mask pre-oxygenation are incorrect.
The nurse is caring for an adult who has had nausea and vomiting for several days and is being admitted to the nursing care unit. The client can follow directions. IV fluids were started in the emergency department. Which action is the highest priority for the nurse at this time?
- A. Offer oral fluids every hour.
- B. Turn every two hours.
- C. Monitor urine output.
- D. Put client in a supine position.
Correct Answer: C
Rationale: Monitoring urine output is critical to assess hydration status and kidney function in a client with prolonged nausea and vomiting, as dehydration is a major risk. IV fluids address dehydration, making oral fluids less urgent, and turning or positioning are secondary.
The nurse is teaching a client with a new diagnosis of depression about fluoxetine (Prozac). Which of the following instructions should the nurse include?
- A. Take the medication at bedtime.
- B. Report any suicidal thoughts.
- C. Stop the medication if mood improves.
- D. Avoid regular mental health follow-ups.
Correct Answer: B
Rationale: Suicidal thoughts are a serious fluoxetine side effect, requiring immediate reporting. Options A, C, and D are incorrect.
An adult who has multiple sclerosis is receiving cyclophosphamide (Cytoxan). The client asks the nurse why she is receiving the same drug her mother had when she had Hodgkin's disease. The nurse should include which information when responding?
- A. Multiple sclerosis is a type of cancer, so the same drugs are effective for both conditions.
- B. A side effect of cyclophosphamide (Cytoxan), a cancer drug, is immunosuppression. In multiple sclerosis, the immune system is attacking the client's nerves.
- C. Hodgkin's disease causes nervous system symptoms similar to those seen in multiple sclerosis.
- D. Multiple sclerosis and Hodgkin's disease are caused by the same organism, so the same drug is appropriate.
Correct Answer: B
Rationale: Cyclophosphamide's immunosuppressive effect reduces immune activity in MS, where the immune system attacks nerves, unlike cancer treatment, symptom similarity, or shared etiology.
Which of the following nursing actions is MOST appropriate?
- A. Place a clock where the client can see it.
- B. Restrain all four extremities.
- C. Keep a light on in the client's room.
- D. Place the side rails in an upright position.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will provide visual cues, safety is more important (2) inappropriate (3) may be appropriate, but is not priority over answer choice #4 (4) correct-side rails should always be in an upright position for a disoriented client