Nokea
The nurse in the newborn nursery is planning for the admission of a large for gestational age (LGA) infant. In preparing to care for this infant, the nurse should obtain equipment to perform which diagnostic test?
- A. Serum insulin level
- B. Heel stick blood glucose
- C. Rh and ABO blood typing
- D. Indirect and direct bilirubin levels
Correct Answer: B
Rationale: After birth, the most common problem in the LGA infant is hypoglycemia, especially if the mother is diabetic. At delivery when the umbilical cord is clamped and cut, maternal blood glucose supply is lost. The newborn continues to produce large amounts of insulin, which depletes the infant's blood glucose within the first hours after birth.
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A child is admitted to the hospital with a diagnosis of nephrotic syndrome. The nurse expects to note documentation of which manifestation in the medical record? Select all that apply.
- A. Edema
- B. Proteinuria
- C. Hypertension
- D. Abdominal pain
- E. Increased weight
- F. Hypoalbuminemia
Correct Answer: A,B,D,E,F
Rationale: Nephrotic syndrome refers to a kidney disorder characterized by edema, proteinuria, and hypoalbuminemia. The child also experiences anorexia, fatigue, abdominal pain, respiratory infection, and increased weight. The child's blood pressure is usually normal or slightly below normal.
The nurse is assigned to give a child a tepid tub bath to treat hyperthermia. After the bath, which action should the nurse take?
- A. Leave the child uncovered for 15 minutes.
- B. Assist the child to put on a cotton sleep shirt.
- C. Take the child's axillary temperature in 2 hours.
- D. Place the child in bed and cover the child with a blanket.
Correct Answer: B
Rationale: Cotton is a lightweight material that will protect the child from becoming chilled after the bath. Option 1 is incorrect because the child should not be left uncovered. Option 3 is incorrect because the child's temperature should be reassessed a half hour after the bath. Option 4 is incorrect because a blanket is heavy and may increase the child's body temperature.
The nurse is caring for a client diagnosed with heart failure who has a magnesium level of 0.75 mEq/L (0.375 mmol/L). Which action should the nurse take?
- A. Monitor the client for irregular heart rhythms.
- B. Encourage the intake of antacids with phosphate.
- C. Teach the client to avoid foods high in magnesium.
- D. Provide a diet of ground beef, eggs, and chicken breast.
Correct Answer: A
Rationale: The normal magnesium level ranges from 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L); therefore, this client is experiencing hypomagnesemia. The client should be monitored for dysrhythmias because magnesium plays an important role in myocardial nerve cell impulse conduction; thus, hypomagnesemia increases the client's risk of ventricular dysrhythmias. The nurse avoids administering phosphate in the presence of hypomagnesemia because it aggravates the condition. The nurse instructs the client to consume foods high in magnesium; ground beef, eggs, and chicken breast are low in magnesium.
The nurse checks a unit of blood received from the blood bank and notes the presence of gas bubbles in the bag. What action should the nurse take?
- A. Return the bag to the blood bank.
- B. Infuse the blood using filter tubing.
- C. Add 10 mL normal saline to the bag.
- D. Agitate the bag to mix contents gently.
Correct Answer: A
Rationale: The nurse should return the unit of blood to the blood bank because the gas bubbles in the bag indicate possible contamination. Whenever administering blood, the nurse would use filter tubing to trap particulate matter. Although normal saline can be infused concurrently with the blood, normal saline or any other substance should never be added to the blood in a blood bag. The bag should not be agitated because this can harm red blood cells.
A client is admitted to the hospital with a diagnosis of right lower lobe pneumonia. The nurse auscultates the right lower lobe, expecting to note which type of breath sounds?
- A. Absent
- B. Vesicular
- C. Bronchial
- D. Bronchovesicular
Correct Answer: C
Rationale: Bronchial sounds are normally heard over the trachea. The client with pneumonia will have bronchial breath sounds over area(s) of consolidation because the consolidated tissue carries bronchial sounds to the peripheral lung fields. The client may also have crackles in the affected area resulting from fluid in the interstitium and alveoli. Absent breath sounds are not likely to occur unless a serious complication of the pneumonia occurs. Vesicular sounds are normally heard over the lesser bronchi, bronchioles, and lobes. Bronchovesicular sounds are normally heard over the main bronchi.