Nokea
The nurse has attended a staff education program about obtaining blood specimens from newborns via heel stick. Which of the following statements by the nurse would require follow-up?
- A. Nonnutritive sucking may help alleviate pain during the puncture.
- B. I will obtain the blood specimen from the center of the newborn's heel.
- C. I will wipe away the first drop of blood prior to obtaining the specimen.
- D. The heel area should be warmed for 3 to 5 minutes prior to the puncture.
Correct Answer: B
Rationale: The center of the heel (B) should be avoided to prevent bone injury; lateral or medial aspects are used. Sucking (A), wiping the first drop (C), and warming (D) are correct.
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The nurse is caring for a woman who has internal radiation for cancer of the cervix. Which of the following situations poses the greatest risk for others?
- A. The client's daughter spends several hours sitting next to the client's bed.
- B. The client's husband kisses her and visits for five minutes before leaving.
- C. The nurse brings the client her lunch tray and sets it up on the overbed table for her.
- D. The cleaning lady damp mops the room.
Correct Answer: A
Rationale: Prolonged close contact (daughter's hours-long visit) increases radiation exposure risk. Brief visits, tray setup, or mopping pose minimal risk.
The pediatric nurse cares for a 16-year-old client who is scheduled for an appendectomy in the morning. Which of the following interventions are appropriate to support the client's psychosocial needs?
- A. Create a strict daily schedule for the client while hospitalized
- B. Encourage the client to have peers visit while hospitalized
- C. Ensure parental presence during any client procedure
- D. Include the client as an active participant when planning care
- E. Support the client in discussing concerns about body image changes
Correct Answer: B,D,E
Rationale: Peer visits (B), active participation (D), and addressing body image (E) support a teen's psychosocial needs. Strict schedules (A) reduce autonomy, and parental presence (C) may not align with the teen's preferences.
The mother of a newborn asks why the nurse is checking the baby's nose. The nurse replies that it is important to check nasal patency because the newborn:
- A. does not have the ability to sneeze.
- B. must breathe through his nose.
- C. is subject to periods of apnea.
- D. has rapid respirations.
Correct Answer: B
Rationale: Newborns are obligate nose breathers, making nasal patency critical to prevent respiratory distress. Sneezing ability, apnea, or rapid respirations are unrelated.
The nurse administers cimetidine (Tagamet) to a 79 year-old male with a gastric ulcer. Which parameter may be affected by this drug, and should be closely monitored by the nurse?
- A. Blood pressure
- B. Liver function
- C. Mental status
- D. Hemoglobin
Correct Answer: C
Rationale: The elderly are at risk for developing confusion when taking cimetidine, a drug that interacts with many other medications.
A 56-year-old client who had a complete hysterectomy 8 months ago is admitted for opiate detoxification. The second day after admission, the client complains of abdominal cramping and sweating. What is the nurse's best response?
- A. Contact the gynecologist for details of the operation
- B. Suspect drug seeking and suggest the client take a walk around the unit
- C. Tell the client she is probably constipated and ask for an order for Milk of Magnesia
- D. Explain to the client that her symptoms are an expected physical response to detoxification and offer comfort medications as ordered
Correct Answer: D
Rationale: Abdominal cramping and sweating are withdrawal symptoms during opiate detoxification, requiring comfort measures and reassurance.