Nokea
The nurse cares for an 8 lb, 8 oz newborn boy. The infant's history indicates that his mother was given magnesium sulfate IV 4 g in 250 ml D5W several hours before delivery. The nurse would be MOST concerned if which of the following was observed?
- A. Temperature 97.6°F (36.5°C).
- B. Apical pulse 140 bpm.
- C. Respirations 18.
- D. BP 80/50.
Correct Answer: C
Rationale: magnesium sulfate can cause slowing of respirations and hyporeflexia; normal respirations 30-60/min
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A client has come to the clinic for a hepatitis B vaccine and asks if he has to be re-vaccinated after his first injection. Which of the following responses by the nurse is BEST?
- A. A booster shot is required yearly.
- B. Additional injections are given at one and six months.
- C. Repeat doses are given at two and four months.
- D. Revaccination is not required.
Correct Answer: B
Rationale: hepatitis B vaccine is repeated at one and six months
A child comes to the school nurse with a honey-colored crusted lesion below her right nostril. Which of the following actions should the nurse take FIRST?
- A. Remove the scab.
- B. Apply a wet cloth to the lesion.
- C. Notify the child's parents.
- D. Contact the health department.
Correct Answer: C
Rationale: describes impetigo, highly infectious superficial bacterial infection; notify parents so they can contact the physician
A four-week-old infant with symptoms of pyloric stenosis is brought to the outpatient clinic by his mother. Which of the following statements would the nurse expect the mother to make about her son's symptoms?
- A. My son's bowel movements have turned black and sticky.
- B. I really have to encourage my son to suck the bottle.
- C. My son is fussy and seems hungry all the time.
- D. My son spits up green liquid after feeding.
Correct Answer: C
Rationale: becomes lethargic, dehydrated, and malnourished
The nurse is obtaining a history on a client with hyperthyroidism. The nurse should report which of the following assessments to the physician?
- A. Anxiety with extreme nervousness.
- B. Slow, sluggish pulse.
- C. Cool, clammy skin.
- D. Husky, slow speech.
Correct Answer: A
Rationale: signs and symptoms of hyperthyroidism are related to an increased metabolic rate
Which of the following nursing actions has the HIGHEST priority for a teenager admitted with burns to 50% of his body?
- A. Counseling regarding problems of body image.
- B. Maintain airborne precautions.
- C. Maintain aseptic technique during procedures.
- D. Encourage peers to visit on a regular basis.
Correct Answer: C
Rationale: A teenager with 50% body burns is at high risk for infection due to loss of skin barrier. Maintaining aseptic technique during procedures is the highest priority to prevent life-threatening infections. Counseling, precautions, and peer visits are important but secondary to infection control.