Nokea
If the nurse documents all the following data, which finding should be reported immediately?
- A. Refusal to eat
- B. Complaint of nausea
- C. Absent bowel sounds
- D. Temperature of 101°F (38.3°C) orally
Correct Answer: C
Rationale: Absent bowel sounds may indicate peritonitis or bowel obstruction, serious complications of appendicitis requiring immediate reporting to prevent further deterioration.
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Which symptom reported by the parents is best indicative of methamphetamine abuse by the adolescent?
- A. Watery eyes
- B. Drowsiness
- C. Excessive nasal drainage
- D. Marked nervousness
Correct Answer: D
Rationale: Methamphetamine, a stimulant, causes marked nervousness due to increased central nervous system activity, making it a key indicator of abuse.
The nurse is caring for a preterm infant who must be fed via bolus gavage feeding. The infant has a 5 French feeding tube already secured in the left naris. The nurse has aspirated the infant’s stomach contents, noting color, amount, and consistency, and has reinserted the residual amount because it was less than one-fourth the previous feeding. Prioritize the remaining steps that the nurse should take to complete this feeding.
- A. Elevate the syringe 6 to 8 inches over the infant’s head.
- B. Position the infant on the right side.
- C. Uncrimp the tubing and allow the feeding to flow by gravity at a slow rate.
- D. Crimp the feeding tube and pour the specified amount of formula or breast milk into the barrel.
- E. Cap the lavage feeding tube.
Correct Answer: D, A, F, C, E, B, G
Rationale: Sequence: Position infant on right side (D) to reduce aspiration risk connect syringe barrel (A) crimp tube and pour formula (F) elevate syringe (C) uncrimp for gravity flow (E) clear tubing with air (B) cap tube (G).
Which response by the nurse provides the best clarification about the disease process?
- A. If you're afraid of getting HIV, you'll be safer if you avoid having sex with past sex partners.
- B. An HIV-positive individual may not develop symptoms of AIDS for years.
- C. HIV can only be transmitted when symptoms of AIDS are present.
- D. The medication prescribed for AIDS also protects against HIV infection.
Correct Answer: B
Rationale: HIV can be asymptomatic for years, during which it is still transmissible, making this clarification critical for understanding the disease process and transmission risk.
The nurse assesses that the 8-hour-old infant’s axillary temperature is 97°F (36.1°C). Which intervention should the nurse implement first?
- A. Document the findings as abnormal.
- B. Place the infant under a radiant warmer.
- C. Feed the infant formula that is warmed.
- D. Call the HCP to report the temperature.
Correct Answer: B
Rationale: An axillary temperature of 97°F is below the normal range (97.7°F–98.9°F). The infant should be gradually rewarmed under a radiant warmer. Documentation follows intervention feeding warm formula is unnecessary and HCP notification is needed only if warming fails.
The nurse finds documentation in the 4-hour-old newborn’s medical record that states,“Clamping of the umbilical cord was delayed until cord pulsations ceased.” When assessing and collecting additional information about the newborn,what effect should the nurse find as a result of the delayed cord clamping?
- A. More rapid expulsion of meconium by the newborn
- B. Increased level of newborn alertness after birth
- C. An increase in the newborn’s initial temperature
- D. An increase in the newborn’s hemoglobin and hematocrit
Correct Answer: D
Rationale: Newborn Hgb and Hct values will be higher when placental transfusion accomplished through delayed cord clamping occurs at birth. Blood volume increases by up to 50% with delayed cord clamping. Meconium passage alertness and temperature are not affected by delayed clamping.