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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A 14-year-old is going home with a permanent tracheostomy. Which comment by the child's mother indicates to the nurse that the parent needs more instruction?
- A. I need to ask the doctor how many times a day I can suction my child.'
- B. I will suction if my child cannot effectively cough up sputum.'
- C. I know my child will not need the same amount of suctioning every day.'
- D. I know I should only suction my child if it is really necessary.'
Correct Answer: A
Rationale: Asking for a fixed suctioning schedule suggests misunderstanding, as suctioning is PRN based on need, indicating a need for further instruction.
The LPN/LVN has delegated basic hygienic care of several clients to a certified nursing assistant. Which action by the nurse will ensure that the clients receive the best care?
- A. Observe the nursing assistant during the performance of all care
- B. Ask the nursing assistant if there were any problems
- C. Check the nursing assistant's charting
- D. Observe the clients following administration of care by the nursing assistants
Correct Answer: D
Rationale: Observing clients post-care ensures care was performed correctly and identifies issues like skin integrity or comfort, ensuring quality. Constant observation, questioning, or charting checks are less direct.
The nurse performs diet teaching for a client with a spinal cord injury at S-3. Which of the following meals, if chosen by the client, would indicate to the nurse that teaching has been effective?
- A. Cheeseburger with tomato and onion.
- B. Spaghetti with meat sauce and green beans.
- C. Tuna fish sandwich with orange juice.
- D. Grilled cheese sandwich and chocolate pudding.
Correct Answer: B
Rationale: Spaghetti with meat sauce and green beans is high-fiber and low-fat, preventing constipation in spinal cord injury. Options A, C, and D are higher in fat or lower in fiber.
Parents are concerned that their 11 year-old child is a very picky eater. The nurse suggests which of the following as the best initial approach?
- A. Consider a liquid supplement to increase calories
- B. Discuss consequences of an unbalanced diet with the child
- C. Provide fruit, vegetable and protein snacks
- D. Encourage the child to keep a daily log of foods eaten
Correct Answer: B
Rationale: Discuss consequences of an unbalanced diet with the child. It is important to educate the preadolescent as to appropriate diet, and the problems that might arise if diet is not adequate.
An elderly client is admitted to a skilled nursing care facility. When doing a skin assessment, the nurse notes a 3-cm round area of partial-thickness skin loss that looks like a blister on the client's sacrum. The nurse interprets this to be a:
- A. stage I pressure ulcer.
- B. stage II pressure ulcer.
- C. stage III pressure ulcer.
- D. stage IV pressure ulcer.
Correct Answer: B
Rationale: A stage II pressure ulcer involves partial-thickness skin loss, often presenting as a blister or shallow open ulcer, matching the description. Stage I is non-blanchable erythema, stage III involves full-thickness loss, and stage IV extends to muscle/bone.