Nokea
The nurse correctly advises the parents to avoid administering medications containing which ingredient to their child who has hemophilia?
- A. Acetaminophen
- B. Aspirin
- C. Ibuprofen
- D. Penicillin
Correct Answer: B
Rationale: Aspirin inhibits platelet function and increases bleeding risk, which is dangerous for a child with hemophilia, a condition characterized by impaired clotting.
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Which question is most important for the nurse to ask the adolescent girl in preparation for X-rays?
- A. Is there any possibility that you're pregnant?
- B. Have you eaten anything in the past 24 hours?
- C. Have you taken any medications in the past 24 hours?
- D. Are you allergic to iodine or shellfish?
Correct Answer: A
Rationale: Asking about pregnancy is critical before X-rays, as radiation can harm a fetus, making it the most important question to ensure safety.
During preoperative preparation, which nursing action is most appropriate?
- A. Give analgesics.
- B. Give nothing by mouth (NPO).
- C. Give an enema.
- D. Apply heat to the abdomen.
Correct Answer: B
Rationale: Keeping the patient NPO prevents aspiration during surgery and reduces complications, as food in the stomach could interfere with anesthesia.
While supervising the LPN,the RN determines that the LPN needs additional instruction in newborn care. Which action by the LPN prompted the nurse’s conclusion?
- A. Assessed the newborn’s heart rate apically
- B. Covered the newborn’s head with a stocking cap
- C. Checked the newborn’s temperature rectally
- D. Positioned the newborn supine while sleeping
Correct Answer: C
Rationale: Rectal temperature checks risk mucosal irritation or perforation. Apical HR assessment stocking caps and supine positioning (to reduce SIDS risk) are correct practices.
If the nurse collects the following data, which assessment finding best indicates the presence of increased intracranial pressure?
- A. Rapid bilateral pupillary response to light
- B. Tympanic temperature of 97.9°F (36.6°C)
- C. Blood pressure of 150/90 mm Hg
- D. Deep tendon reflexes +2
Correct Answer: C
Rationale: Elevated blood pressure (e.g., 150/90 mm Hg) is a sign of increased intracranial pressure, often part of Cushing's triad (hypertension, bradycardia, irregular respirations), indicating brain compression.
The mother of a healthy 15-hour-old term newborn asks the nurse if the PKU blood test could be completed now on her infant because she and her infant are being discharged to home. Which statement should be the basis for the nurse’s response?
- A. The PKU test must be completed when the infant is at least 1 month of age.
- B. The parents must be required to obtain the test within the first week after discharge if completed before 24 hours of age.
- C. The PKU test is best if completed after the infant is 24 hours old but before 7 days of age.
- D. The PKU test is not needed if the infant is tolerating feedings without diarrhea or vomiting.
Correct Answer: C
Rationale: The PKU test is most accurate after 24 hours and before 7 days allowing sufficient protein intake. Early discharge requires follow-up testing and feeding tolerance doesn’t exempt testing.