Nokea
The home health nurse is visiting a client who plans to deliver her baby at home. Which statement by the client indicates an understanding regarding screening for phenylketonuria (PKU)?
- A. I will need to take the baby to the clinic within 24 hours of delivery to have blood drawn.
- B. I will need to schedule a home visit for PKU screening when the baby is 3 days old.
- C. I will remind the midwife to save a specimen of cord blood for the PKU test.
- D. I will have the PKU test done when I take her for her first immunizations.
Correct Answer: B
Rationale: PKU screening is typically performed at 2-3 days of age to ensure accurate results, as earlier testing may yield false negatives.
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The nurse is caring for a 42-year-old client who has a do not resuscitate (DNR) order on the chart. The client tells the nurse, 'I've changed my mind about the DNR. I would like to cancel that and be given whatever care is needed to keep me alive.' Which response by the nurse is correct?
- A. I will notify your health care provider right away.'
- B. I'm glad to hear this. You shouldn't be a DNR at your age.'
- C. Let me call your family and tell them you have changed your mind.'
- D. You cannot change a DNR once it's on your chart. It is a legal document.'
Correct Answer: A
Rationale: A DNR can be revoked by the client at any time. Notifying the provider ensures the change is documented and followed.
A client is admitted with a diagnosis of duodenal ulcer. A common complaint of the client with a duodenal ulcer is:
- A. Epigastric pain that is relieved by eating
- B. Weight loss
- C. Epigastric pain that is worse after eating
- D. Vomiting after eating
Correct Answer: A
Rationale: Duodenal ulcers typically cause epigastric pain that is relieved by eating due to buffering of gastric acid.
The nurse is caring for a client who is postoperative day 3 following a bowel resection. The client reports sudden, severe abdominal pain and distention. Which of the following actions should the nurse take FIRST?
- A. Administer pain medication as ordered.
- B. Notify the physician.
- C. Assess the client’s vital signs and abdomen.
- D. Encourage the client to ambulate.
Correct Answer: B
Rationale: sudden, severe abdominal pain and distention may indicate a complication such as an anastomotic leak, requiring immediate physician notification
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.
The nurse is performing an initial assessment of a newborn Caucasian male delivered at 32 weeks gestation. The nurse can expect to find the presence of:
- A. Mongolian spots
- B. Scrotal rugae
- C. Head lag
- D. Polyhydramnios
Correct Answer: C
Rationale: Head lag is expected in a preterm newborn at 32 weeks due to underdeveloped neck muscle strength.