Nokea
During the check-up of a 2-month-old infant at a well-baby clinic, the mother expresses concern to the nurse because a flat pink birthmark on the baby's forehead and eyelid has not gone away. What is an appropriate response by the nurse?
- A. Mongolian spots are a normal finding in dark-skinned infants.
- B. Port wine stains are typically associated with other malformations.
- C. Telangiectatic nevi are normal and will disappear as the baby grows.
- D. The child is too young for surgical removal of these at this time.
Correct Answer: C
Rationale: The correct answer is C. Telangiectatic nevi, often referred to as 'stork bites,' are common birthmarks in infants and are considered normal. These birthmarks usually fade and disappear as the child grows older. Choices A, B, and D are incorrect because Mongolian spots are bluish-gray birthmarks commonly found in darker-skinned infants, port wine stains are vascular birthmarks that typically do not disappear, and surgical removal is not recommended for telangiectatic nevi as they usually resolve on their own.
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A nurse is preparing an education program for staff about advocacy. What information should the nurse include?
- A. Advocacy ensures clients' safety, health, and rights.
- B. Advocacy involves only supporting client complaints.
- C. Advocacy means making all decisions for the client.
- D. Advocacy is not part of nursing responsibilities.
Correct Answer: A
Rationale: The correct answer is A. Advocacy in nursing involves ensuring clients' safety, health, and rights. Nurses advocate for their clients by promoting autonomy, informed decision-making, and protecting their rights. Choice B is incorrect because advocacy goes beyond just supporting client complaints; it encompasses a broader scope of ensuring holistic care and well-being. Choice C is incorrect as advocacy does not mean making all decisions for the client but rather empowering them to make informed choices. Choice D is incorrect as advocacy is a crucial component of nursing responsibilities, as it involves standing up for clients' best interests and ensuring their rights are respected.
The UAPs working on a chronic neuro unit ask the LPN/LVN to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client?
- A. Place the chair at a right angle to the bed on the client's left side before moving.
- B. Assist the client to a standing position, then place the right hand on the armrest.
- C. Have the client place the left foot next to the chair and pivot to the left before sitting.
- D. Move the chair parallel to the right side of the bed, and stand the client on the right foot.
Correct Answer: D
Rationale: The correct method for transferring an elderly client with left-sided weakness from the bed to the chair involves moving the chair parallel to the right side of the bed and standing the client on the right foot. This technique provides a stable and safe transfer by utilizing the stronger side of the client to support the transfer. Choices A, B, and C are incorrect because placing the chair at a right angle to the bed on the client's left side, assisting the client to a standing position and placing the right hand on the armrest, and having the client pivot to the left before sitting do not address the client's left-sided weakness and may increase the risk of falls or injuries.
A client with a history of atrial fibrillation is taking digoxin (Lanoxin). Which finding should the healthcare provider be notified of immediately?
- A. Heart rate of 52 beats per minute
- B. Blood pressure of 110/70 mmHg
- C. Blood glucose level of 180 mg/dL
- D. Potassium level of 4.0 mEq/L
Correct Answer: A
Rationale: A heart rate of 52 beats per minute is a critical finding in a client taking digoxin, as it may indicate digoxin toxicity. Digoxin can cause bradycardia as a side effect, and a heart rate of 52 bpm warrants immediate attention to prevent adverse outcomes. Monitoring and reporting changes in heart rate are crucial in clients on digoxin therapy to prevent serious complications. The other vital signs and laboratory values provided are within normal ranges or not directly associated with digoxin toxicity in this scenario, making them lower priority for immediate reporting.
A nurse is preparing to insert an IV catheter for an adult client. Which of the following actions should the nurse take?
- A. Choose the most distal site on the selected extremity
- B. Apply a cool compress to the selected extremity before insertion of the IV catheter
- C. Stroke the selected extremity before insertion of the IV catheter
- D. Place the tourniquet above the proposed insertion site
Correct Answer: C
Rationale: When preparing to insert an IV catheter, stroking the extremity before insertion helps to visualize veins, making it easier to locate a suitable vein for catheter insertion. Choosing the most distal site on the extremity is correct because veins more distal are preferred for IV catheter insertion. Applying a cool compress to the extremity before insertion is unnecessary and not a standard practice. Placing the tourniquet below the proposed insertion site is incorrect; the tourniquet should be placed above the proposed insertion site to help engorge the veins for easier visualization and access.
A healthcare professional is reviewing a client's medication prescription, which reads, 'digoxin 0.25 by mouth every day.' Which of the following components of the prescription should the healthcare professional question?
- A. the medication
- B. the route
- C. the dose
- D. the frequency
Correct Answer: C
Rationale: The healthcare professional should question the dose indicated in the prescription. In this case, '0.25' is incomplete without a unit of measurement, such as mg (milligrams). Without a specified unit, the dose lacks the necessary information for accurate administration. Choices A, B, and D are not incorrect components to question in medication prescriptions; however, in this scenario, the incompleteness of the dose is the most critical concern that needs clarification to ensure safe and effective medication administration.