Nokea
The nurse determines that a client understands the purpose of a phytonadione injection for her newborn when she is heard making which statement to the baby's father?
- A. The baby's liver cannot produce that vitamin.
- B. Most newborns need a supplement of this vitamin.
- C. All newborns lack intestinal bacteria to produce this vitamin.
- D. It's unusual but our baby lack's the vitamin that helps the blood to clot.
Correct Answer: C
Rationale: The absence of normal flora needed to synthesize vitamin K (phytonadione) in the normal newborn gut results in low levels of vitamin K and creates a transient blood coagulation deficiency between the second and fifth day of life. An injection is administered prophylactically on the day of birth to combat the deficiency.
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The nurse assists the primary health care provider with the removal of a chest tube. During the procedure, the nurse instructs the client to perform which action?
- A. Inhale deeply.
- B. Breathe normally.
- C. Breathe out forcefully.
- D. Take a deep breath and hold it.
Correct Answer: D
Rationale: The client is instructed to take a deep breath and hold it for chest tube removal. This maneuver will increase intrathoracic pressure, thereby lessening the potential for air to enter the pleural space. Therefore, options 1, 2, and 3 are incorrect.
The nurse reviews the client's vital signs in the client's chart. Based on these data findings, what is the client's pulse pressure? Fill in the blank.
Correct Answer: 74 mm Hg
Rationale: The difference between the systolic and diastolic blood pressure is the pulse pressure. Therefore, if the client has a blood pressure of 146/72 mm Hg, then the pulse pressure is 74.
A client with a posterior wall bladder injury has had surgical repair and placement of a suprapubic catheter. What intervention should the nurse plan to implement to prevent complications associated with the use of this catheter?
- A. Monitor urine output every shift.
- B. Measure specific gravity once a shift.
- C. Encourage a high intake of oral fluids.
- D. Avoid kinking of the catheter tubing.
Correct Answer: D
Rationale: A complication after surgical repair of the bladder is disruption of sutures caused by tension on them from urine buildup. The nurse prevents this from happening by ensuring that the catheter is able to drain freely. This involves basic catheter care, including keeping the tubing free from kinks, keeping the tubing below the level of the bladder, and monitoring the flow of urine frequently. Monitoring urine output every shift is insufficient to detect decreased flow from catheter kinking. Measurement of urine specific gravity and a high oral fluid intake do not prevent complications of bladder surgery.
A low dose of ondansetron is prescribed for a client receiving chemotherapy. The nurse anticipates that the primary health care provider will prescribe the medication by which route?
- A. Oral
- B. Intranasal
- C. Intravenous
- D. Subcutaneous
Correct Answer: C
Rationale: Ondansetron is an antiemetic used to control nausea, vomiting, and motion sickness. It is available for administration by the oral, intramuscular (IM), or intravenous (IV) routes. The IV route is the route used when relief of nausea is needed in the client receiving chemotherapy. The IM route may be used when the medication is used as an adjunct to anesthesia. Option 1 should not be used in clients who are nauseated. Options 2 and 4 are not routes of administration of this medication.
The client diagnosed with chronic kidney disease is scheduled for hemodialysis. When should the nurse plan to administer the client's daily dose of enalapril to ensure its effectiveness?
- A. During dialysis
- B. Just before dialysis
- C. The day after dialysis
- D. Upon return from dialysis
Correct Answer: D
Rationale: Antihypertensive medications, such as enalapril, are administered to the client after hemodialysis. This prevents the client from becoming hypotensive during dialysis and also from having the medication removed from the bloodstream by dialysis. There is no rationale for waiting a full day to resume the medication. This would lead to ineffective control of the blood pressure.