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The nurse developing a plan of care for a postterm small-for-gestational-age (SGA) newborn should identify which assessment as the priority to monitor?
- A. Urinary output
- B. Blood glucose levels
- C. Total bilirubin levels
- D. Hemoglobin and hematocrit
Correct Answer: B
Rationale: The most common metabolic complication in the SGA newborn is hypoglycemia, which can produce central nervous system abnormalities and mental retardation if not corrected immediately. Urinary output, although important, is not the highest priority action; however, the postterm SGA newborn is typically dehydrated from placental dysfunction. Hemoglobin and hematocrit levels are monitored because the postterm SGA newborn exhibits polycythemia, although this also does not require immediate attention. The polycythemia contributes to increased bilirubin levels, usually beginning on the second day after delivery.
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The nurse is monitoring a client with a diagnosis of chronic kidney disease (CKD). Which assessment finding should the nurse report to the primary health care provider?
- A. Pallor
- B. Fatigue
- C. Lethargy
- D. Petechiae
Correct Answer: D
Rationale: CKD can cause damage to many body systems. Hematological manifestations that can occur with this disease include anemia and bleeding. Abnormal bleeding (petechiae; purpura; bruising; bleeding from the mucous membranes, nose, or gums; vaginal bleeding; or intestinal bleeding) should be reported to the primary health care provider because it can be life-threatening. Pallor, fatigue, and lethargy are clinical manifestations associated with anemia.
A 32-year-old woman recently diagnosed with Hodgkin's disease is admitted to the hospital outpatient clinic for staging by undergoing a bone marrow aspiration and biopsy. To obtain more information about the client's nutrition status the nurse should review the results of which of the following tests?
- A. Red blood cell count.
- B. Direct and indirect bilirubin levels.
- C. Reticulocyte count.
- D. Albumin level.
Correct Answer: D
Rationale: Albumin levels reflect nutritional status, as low levels indicate protein malnutrition, common in cancer patients. The other tests assess hematologic or liver function.
A 16-year-old client is in the emergency department for treatment of minor injuries from a car accident. A crisis nurse is with her because she became hysterical and was saying, 'It's my fault. My Mom is going to kill me. I don't even have a way home.' Which of the following should be the nurse's initial intervention?
- A. Hold her hands and say, 'Slow down. Take a deep breath.'
- B. Say, 'Calm down. The police can take you home.'
- C. Put a hand on her shoulder and say, 'It wasn't your fault.'
- D. Say, 'Your mother is not going to kill you. Stop worrying.'
Correct Answer: A
Rationale: This intervention calms the client's hysteria using physical touch and breathing techniques, helping her regain composure before addressing other concerns.
The nurse is teaching a client with a new diagnosis of atrial fibrillation about dabigatran (Pradaxa). Which of the following instructions is most important?
- A. Take the medication with food to reduce stomach upset.
- B. Report any signs of bleeding immediately.
- C. Avoid taking the medication with aspirin.
- D. Store the medication in the refrigerator.
Correct Answer: B
Rationale: Dabigatran, an anticoagulant, increases bleeding risk, so reporting signs of bleeding is critical for safety.
A client with a history of schizophrenia is prescribed olanzapine (Zyprexa). The nurse should monitor the client for which of the following adverse effects?
- A. Weight gain.
- B. Hypoglycemia.
- C. Bradycardia.
- D. Hypotension.
Correct Answer: A
Rationale: Olanzapine commonly causes weight gain, requiring monitoring.