Nokea
Phototherapy is ordered for a newborn with physiologic jaundice. The nurse caring for the infant should:
- A. Offer the baby sterile water between feedings of formula
- B. Apply an emollient to the baby's skin to prevent drying
- C. Wear a gown, gloves, and a mask while caring for the infant
- D. Place the baby on enteric isolation
Correct Answer: B
Rationale: Applying an emollient prevents skin drying, a common issue during phototherapy due to exposure to light.
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The nurse assesses a client who has been re-admitted to the psychiatric inpatient unit for schizophrenia. His symptoms have been managed for several months with fluphenazine (Prolixin). Which should be a focus of the first assessment?
- A. Stressors in the home
- B. Medication compliance
- C. Exposure to hot temperatures
- D. Alcohol use
Correct Answer: B
Rationale: Medication compliance. Ensuring adherence to fluphenazine is critical for symptom management in schizophrenia.
An 86-year-old client with diabetes and gastroparesis has had repeated hospitalizations for aspiration pneumonia following a stroke and is now hospitalized with altered level of consciousness. Which nursing action is most appropriate to decrease the client's risk for developing aspiration pneumonia?
- A. Assessing client's breath sounds every 2 hours
- B. Placing client in the side lying position in bed
- C. Titrating client's oxygen to maintain saturation 93%
- D. Turning and repositioning the client every 2 hours
Correct Answer: B
Rationale: The side-lying position (B) reduces aspiration risk by preventing reflux into the airway, especially in clients with altered consciousness. Assessing breath sounds (A), oxygen titration (C), and repositioning (D) are supportive but less effective for prevention.
An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN?
- A. A middle-aged client who says 'I took too many diet pills' and 'my heart feels like it is racing out of my chest.'
- B. A young adult who says 'I hear songs from heaven. I need money for beer. I quit drinking 2 days ago for my family. Why are my arms and legs jerking?'
- C. An adolescent who was recently diagnosed with leukemia and started chemotherapy with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10
- D. An elderly client who reports having taken a 'large crack hit' 10 minutes prior to walking into the emergency room
Correct Answer: C
Rationale: Nurses who are floated to other units should be assigned to a client who has minimal anticipated immediate complications of their problem. The client in option C exhibits opioid toxicity with the pinpoint pupils and has the least risk of complications occurring in the near future.
Thirty-six hours after major surgery, a client has a temperature of 100°F. What is the most likely cause of the temperature elevation?
- A. Dehydration
- B. Atelectasis
- C. Wound infection
- D. Bladder infection
Correct Answer: B
Rationale: Atelectasis, due to reduced lung expansion post-surgery, is a common cause of low-grade fever within 24–48 hours. Dehydration, wound infection (typically later), or bladder infection are less likely without specific symptoms.
A non-stress test has been ordered for a pregnant client with diabetes mellitus. Non-stress testing is a part of the diabetic's prenatal care because:
- A. Fetal movement is adversely affected by diabetes.
- B. Maternal insulin levels can have a negative effect on fetal energy.
- C. Diabetes can adversely affect development of placental vessels.
- D. Fetal lung maturity is most easily determined by non-stress testing.
Correct Answer: C
Rationale: Diabetes can impair placental vessel development, reducing oxygen and nutrient delivery to the fetus, necessitating non-stress testing to monitor fetal well-being. Fetal movement and lung maturity are assessed differently, and insulin's effect is indirect.