Nokea
Select the criteria that is accurately paired with its indication of birth weight or gestational age.
- A. Low birth weight: The neonate's weight is less than 1,500 g at the time of delivery.
- B. Appropriate for gestational age: The neonate's weight ranges from the 10th to the 90th percentile.
- C. Large for gestational age: The neonate's weight is above the 99th percentile.
- D. Small for gestational age: The neonate's weight is below the 20th percentile.
Correct Answer: B
Rationale: Appropriate for gestational age (AGA) indicates a neonate's weight ranging from the 10th to the 90th percentile. This range signifies that the baby's weight is within the normal range for their gestational age. Choices A, C, and D provide inaccurate information about the criteria and do not correctly correspond to the indicated birth weight or gestational age. Low birth weight typically refers to a weight below 2,500 g, large for gestational age above the 90th percentile, and small for gestational age below the 10th percentile.
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Marlisa has been diagnosed with diabetes mellitus type 1. She asks Nurse Errol what this means. What is the best response by the nurse? Select the one that does not apply.
- A. Your beta cells should be able to secrete insulin, but cannot.
- B. The endocrine function of your pancreas is to secrete insulin.
- C. Without insulin, you will develop ketoacidosis (DKA).
- D. The exocrine function of your pancreas is to secrete Estrogen.
Correct Answer: D
Rationale: Type 1 diabetes is characterized by the inability of the beta cells in the pancreas to secrete insulin. Choice A is correct because it highlights the role of beta cells. Choice B is accurate as the endocrine function of the pancreas includes insulin secretion. Choice C is true as without insulin, ketoacidosis can develop. Choice D is incorrect as the exocrine function of the pancreas involves secreting digestive enzymes, not estrogen.
When reinforcing teaching and instructing the patient, which basic principle of teaching should you follow?
- A. Sequence the instruction from the least complex to the most complex.
- B. Assume that the patient knows little or nothing about the topic.
- C. Tell the patient to call their significant other so you can instruct them.
- D. Use medically oriented terms so the patient will be able to speak with the doctor.
Correct Answer: A
Rationale: The correct principle of teaching to follow when reinforcing teaching and instructing the patient is to sequence the instruction from the least complex to the most complex. This approach facilitates learning by building upon simpler concepts before moving to more advanced ones. Choice B is incorrect because assuming the patient knows little or nothing about the topic may not always be accurate and can be patronizing. Choice C is incorrect as it does not focus on the direct teaching approach to the patient. Choice D is incorrect as using medically oriented terms may confuse the patient rather than facilitate understanding.
A patient's serum potassium level is 2.2 mEq/L. Which nursing action is the highest priority for this patient?
- A. Start oxygen at 2 L/min
- B. Initiate cardiac monitoring
- C. Initiate seizure precautions
- D. Keep the patient on bed rest
Correct Answer: B
Rationale: The correct answer is to initiate cardiac monitoring. Severe hypokalemia can lead to life-threatening arrhythmias, making cardiac monitoring the priority to detect and manage any cardiac complications. Starting oxygen, seizure precautions, or bed rest are not the immediate priority actions for severe hypokalemia.
Ben injects his insulin as prescribed, but then gets busy and forgets to eat. What will the best assessment of the nurse reveal?
- A. The client will be very thirsty.
- B. The client will complain of nausea.
- C. The client will need to urinate.
- D. The client will have moist skin.
Correct Answer: D
Rationale: The correct answer is D. In this scenario, since Ben took his insulin but forgot to eat, he is at risk of developing hypoglycemia. Moist skin is a sign of hypoglycemia, which can occur when blood sugar levels drop too low. Thirstiness (choice A) is more commonly associated with hyperglycemia (high blood sugar levels). Nausea (choice B) and frequent urination (choice C) are not typical immediate signs of hypoglycemia caused by missing a meal after insulin administration.
A charge nurse notices that two staff nurses are not taking meal breaks during their shifts. Which of the following actions should the nurse take first?
- A. Discuss time management strategies with the nurses
- B. Provide coverage for the nurses' breaks
- C. Determine the reasons the nurses are not taking scheduled breaks
- D. Review policies for taking scheduled breaks
Correct Answer: C
Rationale: The correct answer is to determine the reasons the nurses are not taking scheduled breaks. This action is crucial as it allows the charge nurse to understand the underlying causes for the behavior. By identifying the reasons, the nurse can then address the root of the issue effectively. Option A is incorrect because discussing time management strategies may not address the specific reasons for not taking breaks. Option B is incorrect as providing coverage for breaks does not address the underlying cause of the issue. Option D is also incorrect as reviewing policies should come after understanding the reasons for the behavior.