Nokea
Select the 5 findings that require immediate follow-up
- A. Stool results
- B. Hemoglobin and Hematocrit
- C. Respiratory rate
- D. Heart rate
- E. Current medications
- F. Temperature
- G. WIC count
Correct Answer: A,B,D,E,H
Rationale: The correct choices for immediate follow-up are A, B, D, E, and H. Stool results (A) are crucial for detecting gastrointestinal issues. Hemoglobin and hematocrit (B) levels indicate blood health. Heart rate (D) reflects cardiovascular function. Current medications (E) help assess potential drug interactions. WIC count (H) is essential for monitoring infection. Respiratory rate (C) and temperature (F) are important but not as urgent.
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Which of the following actions should the nurse take?
- A. Refer the adolescent to a local mental health clinic.
- B. Advise the adolescent to place the newborn for adoption
- C. Contact the adolescent's parent for assistance
- D. Assist the adolescent in applying for Medicaid
Correct Answer: D
Rationale: Medicaid can provide financial assistance for prenatal care and delivery.
A nurse is performing postmortem care for a recently deceased client prior to the client's family visit. Which of the following actions should the nurse plan to take?
- A. Cross the client's arms across their chest.
- B. Hold the client's eyes shut for a few seconds
- C. Place the client in a high-Fowler's position
- D. Remove the client's dentures from their mouth.
Correct Answer: B
Rationale: The correct answer is B: Hold the client's eyes shut for a few seconds. This action is important to maintain a dignified appearance for the deceased client and to create a peaceful and respectful image for the family during their visit. Crossing the client's arms (A) or placing them in a high-Fowler's position (C) may not be necessary and can be considered unnecessary handling of the body. Removing the client's dentures (D) is not typically part of postmortem care unless specifically instructed. Holding the eyes shut briefly is a culturally sensitive and respectful practice that can help create a serene appearance for the family.
Which of the following questions is the priority for the nurse to ask the client?
- A. How do you manage your behavior?
- B. Do you have a criminal record?
- C. How do you get along with your peers at school?
- D. Do you have thoughts of harming yourself?
Correct Answer: D
Rationale: The correct answer is D. The nurse's priority is to assess for any immediate danger or harm to the client. Asking about thoughts of harming oneself is crucial in determining the client's safety. This question helps identify the client's risk of suicide and allows for timely intervention if needed. Choices A, B, and C focus on different aspects of the client's behavior and relationships, which are important but not as urgent as assessing for suicidal ideation. It is essential to address safety concerns first before exploring other areas.
Which of the following instructions should the nurse include?
- A. Monitor for weight loss
- B. Increase dietary calcium.
- C. Take on an empty stomach.
- D. Schedule dosage at bedtime
Correct Answer: B
Rationale: The correct answer is B: Increase dietary calcium. This instruction is important for a patient likely prescribed with a medication that can deplete calcium levels. Calcium is essential for bone health and overall well-being. Monitoring weight loss (A) is important but not directly related to the medication's side effects. Taking on an empty stomach (C) or at bedtime (D) may be specific to certain medications, but not universally applicable.
After notifying the provider, the nurse should-----and then-----
- A. prepare the client for cardiac catheterization
- B. request a prescription for an increase in statin medication
- C. administer oxygen at 2 L/min via nasal cannula
- D. request a prescription for a beta-blocker
- E. check a STAT cardiac troponin
- F. administer sublingual nitroglycerin
Correct Answer: C,F
Rationale: Oxygen and nitroglycerin are initial interventions for chest pain relief.