Nokea
The experienced nurse and the new nurse are preparing to provide phototherapy to the 4-day-old infant with hyperbilirubinemia. Which information should the experienced nurse include when instructing the new nurse about providing phototherapy for the infant?
- A. Keep the infant fully clothed to prevent chilling and hypothermia.
- B. Cover the infant's eyes with eye shields to prevent retinal damage.
- C. Limit the number of feedings to reduce the number of soiled diapers.
- D. Discontinue the phototherapy if the infant develops a mild skin rash.
Correct Answer: B
Rationale: B: Eye shields protect retinas from phototherapy light. A: Clothing reduces skin exposure, hindering bilirubin conversion. C: Increased feedings aid bilirubin excretion. D: Mild rashes are harmless and don't warrant discontinuation.
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The dietitian prescribes a 24-hour calorie count for the malnourished hospitalized client. Which action should be taken by the nurse?
- A. Ask the client to recall at the end of the day the food and beverages consumed.
- B. Inform the client how to count the calories in the food and beverages consumed.
- C. Inform the client that a record will be maintained of food and beverages consumed.
- D. Ask the client to identify the food groups and foods that are being consumed in each.
Correct Answer: C
Rationale: C: Recording food intake ensures accurate calorie counts. A: Recall is unreliable. B: Clients don't calculate calories in hospital. D: Food groups don't provide calorie data.
The nurse applies a warm, moist compress to the site where an IV solution has infiltrated. Which response is correct when the client asks the purpose of the compress?
- A. The application of moist heat will alter tissue sensitivity by producing numbness.
- B. The application of moist heat will decrease the metabolic needs of the involved tissues.
- C. The application of moist heat will stop the local release of histamine in the tissues.
- D. The application of moist heat will increase blood flow and accelerate tissue healing.
Correct Answer: D
Rationale: D: Warm compresses increase blood flow, promoting healing. A: Cold causes numbness. B: Heat increases metabolic needs. C: Cold reduces histamine release.
A wrong committed by one person against another (or against the property of another) that might result in a civil trial is:
- A. a tort.
- B. a crime.
- C. a misdemeanor.
- D. a felony.
Correct Answer: A
Rationale: Torts are wrongs committed by one person against another person (or against the property of another), which might result in civil trials. A crime is also defined as a wrong against a person or their property but is considered to be against the public as well. Misdemeanors are crimes that are commonly punishable with fines or imprisonment for less than one year, with both or with parole. A felony is a serious crime punishable by imprisonment in a State or Federal penitentiary for more than one year.
Safety measures for using crutches must be taught to clients. Safety measures for the use of crutches include:
- A. properly fitting crutches with rubber tips at the end that provide a four-point gait.
- B. properly fitting crutches, education in the appropriate gait, and strength in the arms.
- C. crutches that fit the way the client chooses and a gait chosen by client.
- D. both legs touching the floor for all gaits.
Correct Answer: B
Rationale: In addition to the rubber tips on the ends of the crutches, the client needs to know the appropriate gait. Arm strength exercises are important, and it is critical that the client be fitted properly for the crutches.
In managing nausea related to Morphine epidural analgesia, the nurse should administer:
- A. Indocin
- B. Codeine
- C. Motrin
- D. Compazine
Correct Answer: D
Rationale: Compazine (prochlorperazine) is an antiemetic effective for opioid-induced nausea, unlike the other options, which are analgesics or anti-inflammatories.