Nokea
Identify this cardiac rhythm strip. Fill in the blank. A. Idioventricular Rhythm B. Bundle Branch Block C. Sinus bradycardia D. Atrial Flutter
- B. Idioventricular Rhythm
- C. Bundle Branch Block
- D. Sinus bradycardia
- E. Atrial Flutter
Correct Answer: C
Rationale: Sinus bradycardia is characterized by a regular rhythm with a rate below 60 beats per minute, assuming the strip shows this pattern.
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The nurse developing a plan of care for a postterm small-for-gestational-age (SGA) newborn should identify which assessment as the priority to monitor?
- A. Urinary output
- B. Blood glucose levels
- C. Total bilirubin levels
- D. Hemoglobin and hematocrit
Correct Answer: B
Rationale: The most common metabolic complication in the SGA newborn is hypoglycemia, which can produce central nervous system abnormalities and mental retardation if not corrected immediately. Urinary output, although important, is not the highest priority action; however, the postterm SGA newborn is typically dehydrated from placental dysfunction. Hemoglobin and hematocrit levels are monitored because the postterm SGA newborn exhibits polycythemia, although this also does not require immediate attention. The polycythemia contributes to increased bilirubin levels, usually beginning on the second day after delivery.
A client is diagnosed with a flail chest. Which characteristics related to breathing should the nurse observe for in the client?
- A. Cyanosis and slow respirations
- B. Slight bradypnea with shallow breaths
- C. Pallor and paradoxical chest movement
- D. Severe dyspnea and paradoxical chest movement
Correct Answer: D
Rationale: The client with flail chest is in obvious respiratory distress. The client has severe dyspnea and cyanosis accompanied by paradoxical chest movement. Respirations are shallow, rapid, and grunting in nature.
During a home visit, the nurse is evaluating an infant for auditory ability. Which of the following is the expected response in an infant with normal hearing?
- A. Stoppage of body movements when sound is introduced.
- B. Evidence of shy and withdrawn behaviors.
- C. Saying 'da-da' by age 5 months.
- D. Absence of squealing by age 4 months.
Correct Answer: A
Rationale: Infants with normal hearing typically pause or stop movements in response to sound, indicating auditory awareness.
The nurse is instructing an unlicensed assistive personnel on the prevention of postoperative pulmonary complications. Which of the following statements indicates that the assistant has understood the nurse's instructions?
- A. I will turn the client every 4 hours.'
- B. I will keep the client's head elevated.'
- C. I should suction the client every 2 hours.'
- D. I will have the client take 5 to 10 deep breaths every hour.'
Correct Answer: D
Rationale: Deep breathing exercises hourly prevent atelectasis and promote lung expansion, key to preventing pulmonary complications.
The nurse identifies the type of presentation shown in the fi gure as which of the following?
- A. Frank breech.
- B. Compound breech.
- C. Complete breech.
- D. Incomplete breech.
Correct Answer: C
Rationale: For a complete breech, the buttocks present, the feet and legs are fl exed on the thighs, and the thighs are fl exed on the abdomen. For a frank breech, the buttocks present with the hips fl exed and the legs extended against the abdomen and chest. This is the most common type of breech presentation. For a compound breech, the buttocks present together with another part, such as a hand. This is a rare occurrence. For an incomplete breech, one or both feet or the knees extend below the buttocks. This can also be termed a single footling or double footling breech.