Nokea
The nurse in the pediatric unit is collecting data from several newly admitted clients. Which finding should the nurse follow up for possible abuse and mandatory reporting?
- A. A 2-month-old who rolled off the changing table and is now lethargic
- B. A 3-month-old with flat bluish discoloration on the buttock that the mother says has been present since birth
- C. A 3-year-old with forehead bruises that the mother says resulted from running into a table
- D. A 4-year-old who pulled boiling water off the stove and has splatter burns on the arms
Correct Answer: A
Rationale: A 2-month-old cannot roll, and lethargy after a fall suggests possible non-accidental head trauma, requiring abuse investigation. Bluish buttock marks may be Mongolian spots (benign), and splatter burns are consistent with an accident.
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The nurse is reinforcing teaching to a client with a history of diverticulitis about lifestyle changes the client should make to reduce the risk of future episodes. Which information should the nurse reinforce to reduce the risk of future episodes? Select all that apply.
- A. Drink plenty of fluids
- B. Exercise regularly
- C. Follow a low-fiber diet
- D. Increase whole grains, fruits, and vegetables in the diet
- E. Increase intake of red meat
Correct Answer: A,B,D
Rationale: Fluids, exercise, and high-fiber foods (whole grains, fruits, vegetables) prevent constipation and reduce diverticulitis risk. Low-fiber diets and red meat increase risk by promoting constipation and inflammation.
A client on the oncology unit is to receive heparin sodium 5 units per kilogram of body weight by subcutaneous route every 4 hours. The client weighs 105.6 lbs. How many units should the client receive in a 24-hour period?
- A. 800
- B. 1080
- C. 1440
- D. 1960
Correct Answer: C
Rationale: The client weighs 48 kg and should receive 5 units/kg, or 240 units every 4 hours. This would be 1440 units in 24 hours. The answers in A, B, and D are incorrect calculations.
The nurse is reviewing the medication profile for a client with chronic obstructive pulmonary disease. Which prescription should the nurse question?
- A. Amlodipine
- B. Codeine
- C. Ipratropium
- D. Methylprednisolone
Correct Answer: B
Rationale: Codeine, an opioid, suppresses cough and respiration, risking respiratory depression in COPD. Amlodipine treats hypertension, ipratropium relieves bronchospasm, and methylprednisolone reduces inflammation, all appropriate for COPD.
The nurse is caring for a client who is attempting to leave the hospital against medical advice. The client is competent to make decisions. Which of the following actions would be essential for the nurse to take?
- A. Provide the client with a copy of the client’s medical record
- B. Tell the client that discharge forms must be signed before leaving
- C. Inform the client that the client cannot return for medical care after leaving
- D. Ensure the health care provider explains the risks of leaving the hospital to the client
Correct Answer: D
Rationale: Ensuring the provider explains risks ensures informed decision-making, protecting the client and minimizing liability. Medical records are not immediately provided, forms are procedural, and barring future care is incorrect.
The nurse is performing a gestational age assessment on a newborn delivered 2 hours ago. When coming to a conclusion using the Ballard scale, which of these factors may affect the score?
- A. Birth weight
- B. Racial differences
- C. Fetal distress in labor
- D. Birth trauma
Correct Answer: C
Rationale: Fetal distress in labor. The effects of earlier distress may alter the findings of reflex responses as measured on the Ballard tool. Other physical characteristics that estimate gestational age, such as amount of lanugo, sole creases and ear cartilage are unaffected by the other factors.