Nokea
The nurse is assessing a newborn 12 hours after birth. Which of the following findings should be reported to the physician?
- A. Heart rate of 120 beats per minute.
- B. Respiratory rate of 40 breaths per minute.
- C. Acrocyanosis.
- D. Capillary refill of 5 seconds.
Correct Answer: D
Rationale: Capillary refill of 5 seconds indicates poor perfusion in a newborn, requiring physician notification.
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The nurse is caring for a client with a history of multiple sclerosis. Which of the following interventions should be included in the plan of care?
- A. Encourage daily exercise.
- B. Limit fluid intake.
- C. Provide a high-fat diet.
- D. Restrict social activities.
Correct Answer: A
Rationale: Daily exercise helps maintain mobility and strength in multiple sclerosis.
A client with chronic kidney disease is on a low-potassium diet. Which food should the nurse advise the client to avoid?
- A. Apples.
- B. Bananas.
- C. Cauliflower.
- D. White bread.
Correct Answer: B
Rationale: Bananas are high in potassium, which must be limited in chronic kidney disease to prevent hyperkalemia.
The nurse is teaching a client with a new diagnosis of asthma about inhaler use. Which of the following instructions should be included for a metered-dose inhaler?
- A. Shake the inhaler before use.
- B. Hold breath for 10 seconds after inhalation.
- C. Rinse the mouth after each use.
- D. Use a spacer if prescribed.
Correct Answer: A, B, D
Rationale: Shaking the inhaler, holding breath, and using a spacer ensure effective medication delivery.
The nurse is assessing a client's disposable closed chest drainage system at the beginning of the shift and notes continuous bubbling in the water-seal chamber. What should the nurse determine is the possible cause of the bubbling?
- A. The system is intact.
- B. A pneumothorax is resolving.
- C. The suction to the system is shut off.
- D. There is an air leak somewhere in the system.
Correct Answer: D
Rationale: Continuous bubbling in the water-seal chamber through both inspiration and expiration indicates that air is leaking into the system. A resolving pneumothorax would show intermittent bubbling in the water-seal chamber with respiration. Shutting the suction off to the system stops bubbling in the suction control chamber, but does not affect the water-seal chamber.
A client with a history of stroke is at risk for aspiration. Which intervention is most appropriate?
- A. Offer thin liquids.
- B. Position upright during meals.
- C. Provide large bites of food.
- D. Encourage rapid eating.
Correct Answer: B
Rationale: Positioning upright during meals reduces aspiration risk by aiding swallowing and gravity.