Nokea
The LPN is preparing to administer an injection of vitamin K to the newborn. The nurse should administer the injection in the:
- A. Rectus femoris muscle
- B. Vastus lateralis muscle
- C. Deltoid muscle
- D. Dorsogluteal muscle
Correct Answer: B
Rationale: The vastus lateralis muscle is the preferred site for vitamin K injection in newborns, offering a large, safe muscle mass away from nerves and vessels, standard for intramuscular prophylaxis against hemorrhagic disease. Rectus femoris is smaller, deltoid underdeveloped, and dorsogluteal risky near sciatic nerve. Nurses use this site for efficacy and safety, teaching parents its purpose in clotting support.
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The nurse questions a doctors order of Morphine sulfate 50 mg, IM for a client with pancreatitis. Which role best fit that statement?
- A. Change agent
- B. Client advocate
- C. Case manager
- D. Collaborator
Correct Answer: B
Rationale: Questioning an inappropriate order like morphine for pancreatitis, which worsens sphincter of Oddi spasm reflects the client advocate role. Nurses protect patient rights and safety by challenging harmful directives, ensuring optimal care (e.g., suggesting alternatives like meperidine). This differs from change agent (lifestyle shifts), case manager (coordination), or collaborator (teamwork), emphasizing advocacy's focus on patient well-being, a core ethical duty in nursing.
Which of the following assessment finding is typical of extracellular fluid loss?
- A. Distended jugular veins
- B. Elevated hematocrit level
- C. Rapid thready pulse
- D. Increased serum sodium level
Correct Answer: C
Rationale: Extracellular fluid loss (e.g., dehydration) reduces blood volume, causing a rapid, thready pulse as the heart compensates for hypovolemia. Distended jugular veins suggest fluid overload, not loss. Elevated hematocrit reflects hemoconcentration, but pulse is a more immediate sign. Increased sodium occurs with water loss, not always fluid volume. Nurses monitor pulse to detect early shock, guiding fluid replacement to restore circulation and prevent organ damage.
Which of the following is considered as an example of intentional tort?
- A. Malpractice
- B. Negligence
- C. Breach of duty
- D. False imprisonment
Correct Answer: D
Rationale: False imprisonment, an intentional tort, involves deliberately restricting someone's freedom, like restraining a competent patient against their will. Malpractice and negligence are unintentional torts, stemming from carelessness or failure to meet standards, not intent. Breach of duty is a negligence component, not a standalone tort. In nursing, intentional torts require purposeful action, and false imprisonment risks legal liability, emphasizing patient rights and consent in care delivery.
What is nurse's primary critical observation when performing an assessment for determining an Apgar score?
- A. Heart rate
- B. Respiratory rate
- C. Presence of meconium
- D. Evaluation of Moro reflex
Correct Answer: A
Rationale: Apgar score assesses newborn vitality at 1 and 5 minutes post-birth across five criteria: heart rate, respiration, muscle tone, reflex, color. Heart rate (choice A) is primary; absent (<60 bpm = 0, <100 = 1, >100 = 2) dictates immediate resuscitation, making it the most critical. Respiratory rate (choice B) follows, but weak/absent breathing often ties to heart rate. Meconium (choice C) isn't scored directly, though it flags distress. Moro reflex (choice D) tests tone/reflex, secondary to vitals. A is correct, as heart rate drives initial intervention. Nurses prioritize it, ensuring rapid response to stabilize the infant.
After a head injury, a client develops a deficiency of antidiuretic hormone (ADH). What should the nurse consider before assessing the patient about the response to secretion of ADH?
- A. Serum osmolality increases
- B. Urine concentration decreases
- C. Glomerular filtration decreases
- D. Tubular reabsorption of water increases
Correct Answer: B
Rationale: ADH deficiency (diabetes insipidus) post-head injury causes dilute urine (B) due to reduced water reabsorption. Osmolality increases (A) is a result, not a cause. GFR (C) isn't primarily affected. Reabsorption (D) decreases. B is correct. Rationale: Low ADH leads to polyuria with low urine concentration, a key assessment in DI, per endocrine trauma care.