Nokea
The nurse at the radiological imaging center is admitting a client for an MRI of the right knee. Which information obtained by the nurse should be reported immediately to the prescribing health care provider?
- A. The client ate a full breakfast that morning
- B. The client has an implantable cardiovascular defibrillator (ICD)
- C. The client is allergic to povidone-iodine
- D. The client took all prescribed cardiac medications before arriving
Correct Answer: B
Rationale: An ICD is a contraindication for MRI due to magnetic interference, requiring immediate reporting. Other findings are less critical.
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The nurse is monitoring a newborn with skin discoloration in the buttock and lumbar area. Which action by the nurse is appropriate?
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- A. Check the newborn's hemoglobin, hematocrit, and platelet levels
- B. Measure and document the size and location of the markings
- C. Notify the registered nurse of the markings immediately
- D. Review the delivery record for evidence of a traumatic birth
Correct Answer: B
Rationale: Skin discoloration in the buttock and lumbar area of a newborn is often due to Mongolian spots (also called congenital dermal melanocytosis). These are benign, flat, bluish-gray patches typically found on the lower back or buttocks. They are more common in infants with darker skin tones and are not harmful, but they can be mistaken for bruises, which raises concern for abuse later on.
The appropriate nursing action is to measure and document the size, shape, and location of the spots in the medical record. This ensures that there is a clear, dated record of the findings to avoid confusion in the future.
The nurse is assessing a client who had surgery 12 hours ago and is receiving IV morphine for incisional pain. It would require immediate follow-up if the client
- A. Has a blood pressure of 106/68 mm Hg
- B. Falls asleep while speaking with the nurse
- C. Reports burning at the IV site during administration of the medication
- D. Reports dizziness when getting out of bed to use the bathroom
Correct Answer: C
Rationale: Burning at the IV site suggests possible extravasation or phlebitis, which can lead to tissue damage or infection, requiring immediate intervention. Low blood pressure, falling asleep, and dizziness are less urgent and can be associated with morphine's expected effects.
The nurse is reviewing discharge teaching with the parent of a pediatric client who has a new tracheostomy. Which of the following statements by the parent would indicate a correct understanding of the teaching?
- A. I will immediately change the tracheostomy tube if my child has difficulty breathing
- B. I will provide deep suctioning frequently to prevent any airway obstruction.
- C. I will remove the humidifier if my child develops more secretions.
- D. I will travel with two tracheostomy tubes, one of the same size and one a size smaller.
Correct Answer: D
Rationale: Carrying two tracheostomy tubes (same and smaller size) is correct for emergency preparedness. Immediate tube changes, frequent deep suctioning, or removing humidifiers can worsen the situation or are unsafe.
The clinic nurse is reviewing self-care management of acne vulgaris with an adolescent client. Which client statement indicates a need for further instruction?
- A. I have been scrubbing my face twice daily with antibacterial soap.
- B. I should buy skin care products that are labeled noncomedogenic.
- C. Maintaining a nutritious diet will help my skin heal.
- D. Picking or squeezing the lesions will worsen my acne.
Correct Answer: A
Rationale: Scrubbing with antibacterial soap can irritate skin and worsen acne. Noncomedogenic products, a nutritious diet, and avoiding picking are correct practices.
The nurse is screening clients for those at risk of developing syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should recognize that the client at highest risk for developing SIADH is a client with
- A. carpal tunnel syndrome
- B. small cell lung cancer
- C. osteomyelitis
- D. sciatica
Correct Answer: B
Rationale: Small cell lung cancer is strongly associated with SIADH due to ectopic ADH production. Other conditions listed are not significant risk factors.