Nokea
During the initial newborn assessment, the nurse finds that a newborn's heart rate is irregular. Which intervention should the nurse implement?
- A. Notify the pediatrician immediately.
- B. Teach the parents about congenital heart defects.
- C. Document the finding in the infant's record.
- D. Apply oxygen via nasal cannula at 3 L/min.
Correct Answer: C
Rationale: The correct intervention when a nurse finds an irregular heart rate in a newborn is to document the finding in the infant's record. An irregular heart rate is a common occurrence in newborns and does not necessarily require immediate medical intervention. Notifying the pediatrician immediately is unnecessary unless there are other concerning symptoms. Teaching the parents about congenital heart defects is not the priority in this situation. Applying oxygen via nasal cannula at 3 L/min is not indicated for an irregular heart rate without further assessment or medical indication.
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The healthcare provider is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which clinical finding is most concerning?
- A. Increased fatigue
- B. Elevated blood pressure
- C. Elevated hemoglobin
- D. Low urine output
Correct Answer: B
Rationale: In a client with chronic kidney disease (CKD) receiving erythropoietin therapy, elevated blood pressure is the most concerning finding. Elevated blood pressure can indicate worsening hypertension, which requires immediate intervention to prevent further damage to the kidneys and other organs. Increased fatigue (choice A) is a common symptom in CKD but may not be as acutely concerning as elevated blood pressure. Elevated hemoglobin (choice C) can be an expected outcome of erythropoietin therapy and is not necessarily concerning. Low urine output (choice D) is important to monitor in CKD but may not be as immediately concerning as elevated blood pressure in this context.
The nurse determines that a client's pupils constrict as they change focus from a far object. What documentation should the nurse enter about this finding?
- A. Pupils reactive to accommodation.
- B. Nystagmus present with pupillary focus.
- C. Peripheral vision intact.
- D. Consensual pupillary constriction present.
Correct Answer: A
Rationale: The correct answer is A: 'Pupils reactive to accommodation.' When pupils constrict as the client changes focus from a far object to a near one, it indicates a normal response known as accommodation. This physiological process allows the eyes to adjust their focus, and it is a healthy finding. Choice B is incorrect because nystagmus is an involuntary eye movement, not related to the change in focus. Choice C is irrelevant to the scenario and does not describe the observed finding. Choice D refers to pupillary constriction in response to light, not accommodation to changes in focus.
The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which clinical finding requires immediate intervention?
- A. Oxygen saturation of 90%
- B. Respiratory rate of 24 breaths per minute
- C. Use of accessory muscles
- D. Inspiratory crackles
Correct Answer: C
Rationale: The correct answer is C: Use of accessory muscles. In a client with COPD receiving supplemental oxygen, the use of accessory muscles is a critical finding that requires immediate intervention. This observation indicates increased work of breathing, suggesting respiratory distress. Addressing this issue promptly is crucial to prevent further respiratory compromise. Choice A, oxygen saturation of 90%, is slightly below the normal range but may not require immediate intervention unless it continues to decrease. Choice B, a respiratory rate of 24 breaths per minute, is within normal limits for an adult and does not indicate an urgent issue. Choice D, inspiratory crackles, may be present in COPD due to secretions or inflammation but do not necessitate immediate intervention unless associated with other concerning signs.
In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?
- A. Watery diarrhea
- B. Nausea
- C. Headache
- D. Dizziness
Correct Answer: A
Rationale: The correct answer is A: Watery diarrhea. This finding is the most important to report as it may indicate Clostridioides difficile infection, a severe side effect of antibiotic therapy. Clostridioides difficile infection can lead to serious complications and requires immediate medical attention. Choices B, C, and D are common side effects of linezolid but are not as critical as watery diarrhea in this context.
The nurse is caring for a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which laboratory value should be closely monitored?
- A. Serum potassium level
- B. Hemoglobin level
- C. White blood cell count
- D. Serum calcium level
Correct Answer: A
Rationale: The correct answer is A: Serum potassium level. When a client with chronic kidney disease is receiving erythropoietin therapy, monitoring serum potassium levels is crucial due to the risk of developing hyperkalemia. Erythropoietin can stimulate red blood cell production, leading to an increase in potassium levels. Monitoring potassium helps prevent complications associated with hyperkalemia, such as cardiac arrhythmias. Choices B, C, and D are incorrect because while hemoglobin levels are relevant in assessing the effectiveness of erythropoietin therapy, monitoring potassium levels is more critical in this scenario.