Nokea
The nurse is assessing a comatose client receiving gastric tube feedings. Which of the following assessments requires an immediate response from the nurse?
- A. Decreased breath sounds in right lower lobe
- B. Aspiration of a residual of 100 cc of formula
- C. Decrease in bowel sounds
- D. Urine output of 250 cc in past 8 hours
Correct Answer: A
Rationale: Decreased breath sounds in right lower lobe. The most common problem associated with enteral feedings is atelectasis. Maintain client at 30 degrees of head elevation during feedings and monitor for signs of aspiration. Check for tube placement prior to each feeding or every 4 to 8 hours if the client is receiving continuous feeding.
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The nurse is reviewing laboratory data for a client admitted to the emergency department with chest pain. Which serum value requires immediate action by the nurse?
- A. glucose 200 mg/dL (11.1 mmol/L)
- B. hematocrit 38% (0.38)
- C. potassium 3.4 mEq/L (3.4 mmol/L)
- D. troponin T 0.7 ng/mL (0.7 mcg/L)
Correct Answer: D
Rationale: Elevated troponin T (0.7 ng/mL) indicates myocardial injury, requiring immediate action for possible myocardial infarction. Other values are less critical.
The nurse caring for newborns observes for jaundice. Which type of jaundice is likely to be most serious?
- A. Jaundice that occurs during the first day of life
- B. Jaundice occurring after 48 hours of life
- C. Jaundice occurring 7 to 10 days after birth
- D. Any jaundice is potentially life threatening.
Correct Answer: A
Rationale: Jaundice within the first 24 hours suggests pathological causes like hemolytic disease, requiring urgent evaluation. Later jaundice is often physiologic and less severe.
The nurse is reinforcing teaching about circumcision care with the parent of a newly circumcised newborn. Which statement by the parent would require follow-up?
- A. I should change my baby's diaper at least every 4 hours.
- B. I should notify the health care provider if there is odorous discharge from the site.
- C. I will apply light pressure with gauze if there is bleeding at the site.
- D. I will clean the site with alcohol-based wipes or soap and water.
Correct Answer: D
Rationale: Alcohol-based wipes are too harsh for a circumcision site; gentle soap and water are recommended, requiring follow-up. Other statements are correct.
Which of the following meals provides the lowest amount of potassium?
- A. Orange, cream of wheat, bacon
- B. Toast, jelly, soft boiled egg
- C. Raisin bran, milk, grapefruit
- D. Melon, pancakes, milk
Correct Answer: B
Rationale: Toast, jelly, and soft-boiled egg are low in potassium compared to fruits like oranges, grapefruit, or melon, which are high in potassium.
A client is seen in the clinic and determined to have a hydatidiform mole. Which diagnostic test can confirm the diagnosis of a hydatidiform mole?
- A. An ultrasound
- B. Alpha-fetoprotein
- C. Human chorionic gonadotrophin
- D. Lecithin sphingomyelin ratio
Correct Answer: A
Rationale: Ultrasound is the primary diagnostic tool for confirming a hydatidiform mole, showing a characteristic 'snowstorm' pattern. Elevated human chorionic gonadotropin supports the diagnosis but is not confirmatory alone.