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The nurse in the newborn nursery receives report from the previous shift. Which of the following infants should the nurse see FIRST?
- A. A two-day-old infant, lying quietly alert, heart rate of 185 bpm.
- B. A one-day-old infant, crying, and the anterior fontanel is bulging.
- C. A 12-hour-old infant, held by the mother, respirations 45 and irregular.
- D. A five-hour-old infant, sleeping, hands and feet are blue bilaterally.
Correct Answer: A
Rationale: A heart rate of 185 bpm indicates tachycardia (normal 120–160 bpm), suggesting distress or dehydration, requiring immediate assessment. Options B, C, and D are less urgent or normal.
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A client receiving HTZ (hydrochlorothiazide) is instructed to increase her dietary intake of potassium. The best snack for the client requiring increased potassium is:
- A. A pear
- B. An apple
- C. An orange
- D. A banana
Correct Answer: D
Rationale: Hydrochlorothiazide is a diuretic that can cause potassium loss. Bananas are high in potassium, making them the best choice. Pears , apples , and oranges have less potassium.
The nurse is teaching a client with a new diagnosis of hyperlipidemia about atorvastatin (Lipitor). Which of the following statements by the client indicates a need for further teaching?
- A. I should report muscle pain to my doctor.
- B. I should take this medication at night.
- C. I should avoid drinking grapefruit juice.
- D. I should stop this medication if my cholesterol is normal.
Correct Answer: D
Rationale: Stopping atorvastatin when cholesterol is normal is incorrect, as hyperlipidemia often requires lifelong treatment to prevent cardiovascular events. Options A, B, and C are correct: muscle pain may indicate myopathy, nighttime dosing maximizes efficacy, and grapefruit juice increases drug levels.
A client with acute leukemia has developed oral ulcerations. The nurse can increase the client's comfort by suggesting that he:
- A. Avoid brushing his teeth until the ulcers heal.
- B. Rinse his mouth frequently with normal saline.
- C. Rinse his mouth frequently with hydrogen peroxide.
- D. Cleanse his teeth and mouth with lemon and glycerin swabs.
Correct Answer: B
Rationale: Normal saline rinses are gentle and help keep the mouth clean without irritating oral ulcerations.
A nurse is caring for a 37-year-old woman with metastatic ovarian cancer admitted for nausea and vomiting.
- A. What is the best indication that the nutritional status of a woman with metastatic ovarian cancer has improved after 4 days of TPN?
- B. The patient eats most of the food served to her.
- C. The patient has gained 1 pound since admission.
- D. The patient’s albumin level is 0 mg/dL.
- E. The patient’s hemoglobin is 8.5 g/dL.
Correct Answer: C
Rationale: Albumin levels (normal 5–5.0 g/dL) are the best indicator of long-term nutritional status, reflecting protein stores. A level of 0 mg/dL indicates improved nutrition. Eating more, weight gain (which may be fluid), or hemoglobin levels (affected by cancer or chemotherapy) are less reliable indicators.
The nurse is caring for a patient the first day postoperative after a transurethral prostatectomy (TURP). The patient has a continuous bladder irrigation (CBI). The patient's wife asks why he has Vectors are not supported in text mode. Please provide the text content you want to include, and I'll help format it appropriately. to have the CBI. Which of the following responses by the nurse is BEST?
- A. The CBI prevents urinary stasis and infection.
- B. The CBI dilutes the urine to prevent infection.
- C. The CBI enables urine to keep flowing.
- D. The CBI delivers medication to the bladder.
Correct Answer: C
Rationale: continuous bladder irrigation prevents formation of clots that can lead to obstruction and spasm in the postoperative TURP client