Nokea
The nurse is assessing a neonate born to a diabetic mother. Which of the following findings should the nurse expect to see in the infant?
- A. Hypertonia
- B. Hyperactivity
- C. Large size
- D. Scaly skin
Correct Answer: C
Rationale: Neonates born to diabetic mothers are often macrosomic (large size) due to maternal hyperglycemia. Hypertonia, hyperactivity, and scaly skin are not typical findings.
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A client who is recovering from transurethral resection of the prostate (TURP) experiences urinary incontinence. He tells the nurse that he has decreased his fluid intake because of the incontinence. What would be the nurse's best response to the client?
- A. Yes, limiting your fluids can decrease your incontinence.'
- B. Limiting your fluids will cause kidney stones.'
- C. I think eight glasses of water a day and urinate every 2 hours.'
- D. If your incontinence continues, we will reinsert your catheter.'
Correct Answer: C
Rationale: Encouraging adequate fluid intake (eight glasses) and scheduled voiding (every 2 hours) helps manage incontinence and maintain urinary health post-TURP.
The nurse caring for a child diagnosed with a patent ductus arteriosus should base planning on which fact concerning this disorder?
- A. It involves an opening between the two atria.
- B. It produces abnormalities in the atrial septum.
- C. It involves an opening between the two ventricles.
- D. It involves an artery that connects the aorta and the pulmonary artery.
Correct Answer: D
Rationale: Patent ductus arteriosus is described as an artery that connects the aorta and the pulmonary artery during fetal life. It generally closes spontaneously within a few hours to several days after birth. It allows abnormal blood flow from the high-pressure aorta to the low-pressure pulmonary artery, resulting in a left-to-right shunt. The remaining options are not characteristics of this cardiac defect.
What are the nursing implications associated with administering blood and blood products to a client who has a blood type of B negative?
- A. The nurse must be knowledgeable about the fact that this client has A and B agglutinins and lacks the Rh factor
- B. The nurse must be knowledgeable about the fact that this client has B and O agglutinins and lacks the Rh factor
- C. The nurse must be knowledgeable about the fact that this client has B agglutinins and lacks the Rh factor
- D. The nurse must be knowledgeable about the fact that this client has A agglutinins and lacks the Rh factor
Correct Answer: C
Rationale: B negative blood type has anti-A agglutinins (antibodies against A antigen) and lacks the Rh factor, requiring careful matching to avoid transfusion reactions.
The nurse assesses the environmental safety of a client receiving home oxygen therapy. Which observation by the nurse indicates that the client needs further teaching to ensure safety?
- A. Oxygen used 30 feet from a gas stove
- B. Oxygen tank stored in the tank holder
- C. No smoking' sign posted at the front door
- D. Oxygen concentrator propped against a wall
Correct Answer: D
Rationale: The oxygen concentrator should be free and clear of walls or other enclosed spaces to allow adequate air circulation around the unit; otherwise, the unit can overheat and increase the risk of fire. Clients should avoid using oxygen within 10 feet of open flames because oxygen fuels a fire. Oxygen tanks are secured in a holder to stabilize and protect the tank, and a 'no smoking' sign should be in view to alert visitors about the risk.
A client with a history of depression is prescribed trazodone (Desyrel). The nurse should instruct the client to take the medication:
- A. In the morning to avoid sedation.
- B. At bedtime to promote sleep.
- C. With meals to enhance absorption.
- D. As needed for low mood.
Correct Answer: B
Rationale: Trazodone is sedating and should be taken at bedtime to promote sleep and manage depression.