Nokea
Which of the following actions should the nurse include in the plan?
- A. Maintain eye contact with the newborn during feedings
- B. Minimize noise in the newborn's environment.
- C. Swaddle the newborn with his legs extended
- D. Administer naloxone to the newborn.
Correct Answer: B
Rationale: Minimizing noise and stimuli helps to reduce symptoms of neonatal abstinence syndrome.
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After puncturing the skin with the vascular access device and noting a blood return in the flashback chamber, which of the following actions should the nurse perform next?
- A. Flush the catheter with saline
- B. Retract the stylet
- C. Advance the catheter into the vein
- D. Release the tourniquet
Correct Answer: C
Rationale: The correct answer is C: Advance the catheter into the vein. After confirming blood return in the flashback chamber, advancing the catheter ensures proper placement within the vein for medication delivery. Retracting the stylet (B) prematurely can displace the catheter. Flushing with saline (A) before confirming placement is risky. Releasing the tourniquet (D) is done after securing catheter placement.
Which of the following information provided by the client indicates improvement? Select all that apply.
- A. The client reports frequent toothaches and lack of dental care
- B. The client makes eye contact and smiles when speaking.
- C. The client's adult child prepares two muss per day for the client.
- D. The client's clothing is clean and appropriate for the weather.
- E. The client has gained 1.11 kg 14 ibL BMI is 18.9
- F. The client receives three baths per week from a home care aide.
Correct Answer: B,C,D,E,F
Rationale: Improvement signs encompass hygiene, nutrition, weight gain, and social interaction.
Which of the following instructions should the nurse include in the teaching?
- A. Apply cold packs directly on the skin of the affected joints
- B. Administer biological response modifiers to prevent infection
- C. Take a hot shower in the morning to decrease stiffness
- D. Cluster physical activities during the day
Correct Answer: C
Rationale: The correct answer is C: Take a hot shower in the morning to decrease stiffness. This instruction is appropriate for managing symptoms of arthritis by helping to reduce stiffness in the joints. Cold packs directly on the skin (choice A) can worsen symptoms. Administering biological response modifiers (choice B) is not a nursing role. Clustering physical activities during the day (choice D) can help manage symptoms but is not as specific or targeted as a hot shower for reducing stiffness.
The nurse should first address the client's.... followed by the client's....
- A. lung, sounds
- B. pain level
- C. bowel sounds
- D. blood glucose level
- E. blood pressure
- F. temperature
Correct Answer: E,F
Rationale: The correct answer is E,F. Firstly, addressing the client's blood pressure (E) is crucial as it assesses cardiovascular health and can indicate potential immediate risks. Secondly, addressing the client's temperature (F) is important as it can indicate infection or other health issues. Choices A, B, C, and D are not the priority as they do not directly relate to immediate cardiovascular or infection risks like blood pressure and temperature do.
A nurse is caring for a 2-year-old toddler. Which of the following food choices should the nurse recommend to promote independence in eating?
- A. Banana slices
- B. Grapes
- C. Hot dog
- D. Popcorn
Correct Answer: A
Rationale: The correct answer is A: Banana slices. Toddlers at the age of 2 are developing their fine motor skills and independence. Banana slices are easy for toddlers to pick up and eat independently, promoting their self-feeding skills. Grapes pose a choking hazard due to their size and shape. Hot dogs are also a choking hazard as they can easily get stuck in a toddler's throat. Popcorn is a common choking hazard for young children due to its hard texture. Therefore, recommending banana slices will not only promote independence in eating but also ensure safety for the toddler.