Nokea
The body part that would most likely display jaundice in the dark-skinned individual is the:
- A. Conjunctiva of the eye
- B. Soles of the feet
- C. Roof of the mouth
- D. Shins
Correct Answer: A
Rationale: The conjunctiva of the eye is the most reliable site to assess jaundice in dark-skinned individuals, as it is less affected by skin pigmentation.
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The nurse is caring for a client diagnosed with glaucoma. The health care provider has ordered timolol maleate. Which finding in the client's history would prompt the nurse to notify the health care provider?
- A. asthma
- B. migraines
- C. atrial fibrillation
- D. urinary tract infection
Correct Answer: A
Rationale: Timolol, a beta-blocker, can exacerbate asthma by causing bronchoconstriction. Other conditions are not contraindications.
The nurse gives a 35-year-old primigravida client a RhoGAM injection in her 27th week of pregnancy. Which of the following client situations requires the nurse to take this action?
- A. Rh-negative mother and Rh-positive father
- B. Rh-negative mother and Rh-negative father
- C. Rh-positive mother and Rh-negative father
- D. Rh-positive mother and Rh-positive father
Correct Answer: A
Rationale: RhoGAM is given to an Rh-negative mother with an Rh-positive father to prevent Rh incompatibility issues in the fetus.
A 5-month-old infant is admitted to the ER with a temperature of 103.6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:
- A. Periorbital edema
- B. Tenseness of the anterior fontanel
- C. Positive Babinski reflex
- D. Negative scarf sign
Correct Answer: B
Rationale: Tenseness of the anterior fontanel indicates increased intracranial pressure, a critical finding in bacterial meningitis in infants.
The nurse is making assignments for the day. The staff consists of an RN, a novice RN, an LPN, and a nursing assistant. Which client should be assigned to the RN?
- A. A client with peptic ulcer disease
- B. A client with skeletal traction for a fractured femur
- C. A client with an abdominal cholecystectomy
- D. A client with an esophageal tamponade
Correct Answer: D
Rationale: The client with an esophageal tamponade requires complex monitoring and intervention, best suited for an experienced RN.
A nurse is caring for an 84-year-old client who is malnourished. The nurse is concerned about all of the following complications of malnutrition EXCEPT
- A. increased risk for falls.
- B. poor wound healing.
- C. chronic heart failure.
- D. increased risk of infections.
Correct Answer: C
Rationale: Malnutrition increases fall risk, impairs wound healing, and raises infection risk due to weakened immunity. Chronic heart failure is not directly caused by malnutrition.