Nokea
The mother of a neonate delivered at 36 weeks' gestation asks why the neonate is being treated for sepsis when no infection is present. Which of the following responses by the nurse is most appropriate?
- A. The neonate may have an infection that we haven't identified yet.'
- B. Premature neonates are more susceptible to infections.'
- C. This is a precautionary measure because the neonate is premature.'
- D. Antibiotics are given to all neonates born before 37 weeks.'
Correct Answer: C
Rationale: Treating a 36-week neonate for sepsis is often precautionary due to their increased risk of infection, even without confirmed infection, to prevent complications.
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The nurse is teaching a client with a new diagnosis of gout about medication management. Which of the following medications should the client expect to take for long-term management?
- A. Allopurinol.
- B. Colchicine.
- C. Indomethacin.
- D. Prednisone.
Correct Answer: A
Rationale: Allopurinol reduces uric acid production for long-term gout management.
The nurse performing tracheostomy care has replaced the tracheostomy tube holder (tracheostomy ties). Which is an effective measure for the nurse to use when determining if the holder is not too tight?
- A. The client nods that he or she feels comfortable.
- B. Two fingers can be slid comfortably under the holder.
- C. Four fingers can be slid comfortably under the holder.
- D. The tracheostomy does not move more than 0.5 inch when the client coughs.
Correct Answer: B
Rationale: There should be enough room for two fingers to slide comfortably under the tracheostomy holder. This ensures that the holder is tight enough to prevent tracheostomy dislocation, while preventing excessive constriction around the neck. The other options are incorrect.
A registered nurse (RN) is supervising a licensed practical nurse (LPN) providing care to a client with end-stage heart failure. The client is withdrawn, is reluctant to talk, and shows little interest in participating in hygienic care or activities. Which statement by the LPN to the client indicates that the LPN needs further teaching in the use of therapeutic communication skills?
- A. You are very quiet today.
- B. What are your feelings right now?
- C. Why don't you feel like getting up?
- D. Tell me more about your difficulty with sleeping at night.
Correct Answer: C
Rationale: When a 'why' question is made to the client, an explanation for feelings and behaviors is requested, and the client may not know the reason. Requesting an explanation is a nontherapeutic communication technique. In option 1, the LPN is using the therapeutic communication technique of acknowledging the client's behavior. In option 2, the LPN is encouraging identification of emotions or feelings. In option 4, the LPN is using the therapeutic communication technique of exploring, which is asking the client to describe something in more detail or to discuss it more fully.
Select the complication of a blood transfusion that is accurately paired with its preventive measure.
- A. Hemolysis: Typing and cross matching the blood and checking for ABO compatibility prior to administration
- B. Hemolysis: Insuring that the client does not have a prior history of hemolysis in the past
- C. Febrile reactions: Insuring that the client does not have a prior history of hemolysis in the past
- D. Febrile reactions: Typing and cross matching the blood and checking for ABO compatibility prior to administration
Correct Answer: A
Rationale: Hemolysis is prevented by ensuring ABO compatibility and proper typing and cross-matching to avoid immune reactions.
The nurse is caring for a client taking memantine. Which data should the nurse monitor for this client?
- A. Liver function studies
- B. Complete blood count
- C. Renal function studies
- D. Pulmonary function studies
Correct Answer: C
Rationale: Memantine is a medication used to treat moderate to severe Alzheimer's disease. This medication needs to be avoided in clients with severe renal dysfunction, and a reduced dosage is needed in moderate renal dysfunction. The other options are not specifically associated with this medication.