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Assessment findings of a 3-hour-old newborn include: axillary temperature of 97.7°F, heart rate of 140 beats/minute with a soft murmur, and irregular respiratory rate at 42 breaths/min. Based on these findings, what action should the nurse implement?
- A. Place a pulse oximeter on the heel
- B. Swaddle the infant in a warm blanket
- C. Record the findings on the flow sheet
- D. Check the vital signs in 15 minutes
Correct Answer: C
Rationale: The correct action for the nurse to take in this scenario is to record the findings on the flow sheet. The newborn's axillary temperature, heart rate, and respiratory rate are within normal limits for a 3-hour-old newborn. Therefore, there is no immediate need for intervention or further assessment. Swaddling the infant in a warm blanket, placing a pulse oximeter on the heel, or checking the vital signs in 15 minutes are not necessary actions based on the normal assessment findings presented. These actions could potentially disrupt the newborn or lead to unnecessary interventions when the baby is stable.
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The healthcare provider prescribes lidocaine (Lidoject-1) 100 mg IV push for ventricular tachycardia for an unconscious client. What is the nurse's priority intervention?
- A. Measure the client's cardiac output
- B. Assess neurological status q15 min
- C. Collect a blood specimen for serum potassium
- D. Infuse lidocaine (Lidoject-1) at 20 to 50 mg/min
Correct Answer: B
Rationale: The priority intervention for the nurse is to assess the client's neurological status q15 min. This is crucial to monitor for potential side effects of lidocaine, especially its neurotoxic effects. While measuring the client's cardiac output and collecting a blood specimen for serum potassium are important assessments, assessing the neurological status is the priority when administering lidocaine. Infusing lidocaine at a specific rate should follow the initial assessment of the client's neurological status to ensure safety.
After implementing a new fall prevention protocol on the nursing unit, which action by the nurse-manager best evaluates the protocol's effectiveness?
- A. Compare the number of falls that occurred before and after protocol implementation
- B. Analyze data that reflects the unit's costs incurred due to the new protocol
- C. Conduct a chart review on the unit to determine the number of clients at risk for falling
- D. Consult with the physical therapist to evaluate the benefits of the new fall protocol
Correct Answer: A
Rationale: The best way to evaluate the effectiveness of a new fall prevention protocol is by comparing the number of falls that occurred before and after its implementation. This direct comparison helps in assessing the impact of the protocol on reducing fall rates. Choices B, C, and D do not directly measure the effectiveness of the protocol. Analyzing costs incurred (Choice B), conducting a chart review (Choice C), or consulting with a physical therapist (Choice D) may provide valuable information but do not specifically evaluate the protocol's effectiveness in preventing falls.
The healthcare provider prescribed furosemide for a 4-year-old child with a ventricular septal defect. Which outcome indicates to the nurse that this pharmacological intervention was effective?
- A. Urine specific gravity changing from 1.021 to 1.031
- B. Daily weight decrease of 2 pounds (0.9 kg)
- C. Blood urea nitrogen (BUN) increasing from 8 to 12 mg/dl (2.9 to 4.3)
- D. Urinary output decreasing by 5 ml/hour
Correct Answer: B
Rationale: The correct answer is B. A daily weight decrease of 2 pounds (0.9 kg) is the most appropriate outcome to indicate the effectiveness of furosemide in a child with a ventricular septal defect. Furosemide is a diuretic medication that helps reduce fluid retention. Therefore, a decrease in weight reflects a reduction in fluid volume, which is the desired effect of furosemide. Choices A, C, and D are incorrect because changes in urine specific gravity, blood urea nitrogen (BUN) levels, and urinary output do not directly reflect the effectiveness of furosemide in this context.
A child with heart failure (HF) is taking digitalis. Which sign indicates to the nurse that the child may be experiencing digitalis toxicity?
- A. Tachycardia
- B. Dyspnea
- C. Vomiting
- D. Muscle cramps
Correct Answer: C
Rationale: Vomiting is a common sign of digitalis toxicity and should be closely monitored. While tachycardia is a common sign of heart failure, it is not typically associated with digitalis toxicity (Choice A). Dyspnea (Choice B) and muscle cramps (Choice D) are not specific signs of digitalis toxicity and can be present in other conditions. Therefore, the presence of vomiting should raise concerns about digitalis toxicity in the child with heart failure.
A client who is bleeding after a vaginal delivery receives a prescription for methylergonovine (Methergine) 0.4 mg IM every 2 hours, not to exceed 5 doses. The medication is available in ampules containing 0.2 mg/ml. What is the maximum dosage in mg that the nurse should administer to this client? (Enter numeric value only)
- A. 2
- B. 3
- C. 4
- D. 5
Correct Answer: A
Rationale: To calculate the maximum dosage in mg that the nurse should administer, multiply the dose per administration (0.4 mg) by the maximum number of doses allowed (5 doses): 0.4 mg/dose * 5 doses = 2 mg. Therefore, the nurse should administer a maximum dosage of 2 mg to the client. Choices B, C, and D are incorrect as they do not reflect the correct calculation based on the provided information.