Nokea
The nurse is assessing a newborn 24 hours after birth. Which of the following findings would require further evaluation?
- A. Heart rate of 140 beats per minute.
- B. Respiratory rate of 40 breaths per minute.
- C. Presence of milia on the nose.
- D. Caput succedaneum crossing the suture line.
Correct Answer: C
Rationale: milia are normal, but persistent or widespread milia may indicate other issues; other findings are within normal limits for a newborn
You may also like to solve these questions
A client with terminal lung cancer is admitted to the unit. A family member asks the nurse, 'How much longer will it be?' Which response by the nurse is most appropriate?
- A. This must be a terrible situation for you.
- B. I don't know. I'll call the doctor.
- C. I cannot say exactly. What are your concerns at this time?
- D. Don't worry, it will be very soon.
Correct Answer: C
Rationale: This response acknowledges the family's concern, provides an honest answer, and opens the conversation to address their specific worries, promoting therapeutic communication.
The nurse is caring for a client after an open reduction to the left ulna. The client's left arm is in a plaster cast with an Ace wrap for reinforcement. Which intervention by the nurse can offer nonpharmacological comfort to this client?
- A. elevate the left arm on a pillow and apply an ice pack over the approximate location of the surgical incision
- B. call the physician and obtain an order for acetaminophen (Tylenol) 650 mg PO PRN q6 hours as needed for pain
- C. advise the client that if he starts to itch under the cast, he can use a wire coat hanger or an ink pen to gently scratch up under the cast
- D. perform range-of-motion exercises twice a shift, including bending the fingers, opening and closing the hand, and lifting the arm up to shoulder level
Correct Answer: A
Rationale: Elevation and ice reduce swelling and pain nonpharmacologically. Scratching under the cast risks skin damage, and excessive movement may disrupt healing.
The physician has ordered a low-purine diet for a client with gout. Which protein source is high in purine?
- A. Dried beans
- B. Nuts
- C. Cheese
- D. Eggs
Correct Answer: A
Rationale: Dried beans are high in purines, which can increase uric acid levels and exacerbate gout symptoms.
Two nurses are preparing to pull a client up in the bed. Which actions by the nurses are correct in regard to safe client handling? Select all that apply.
- A. place the bed in the lowest position possible
- B. ask the client to cross her arms over her chest if she is able
- C. use a patient lifting device, such as a Hoyer lift, if needed
- D. extend the elbows out away from the body while pulling client up
- E. place the head of the bed flat or slightly Trendelenburg if the client can tolerate it
Correct Answer: B, C, E
Rationale: Asking the client to cross arms, using a lifting device if needed, and flattening the bed or using slight Trendelenburg promote safe handling. The bed should be at working height, and elbows should stay close to the body.
The nurse is caring for a client with a head injury who has an intracranial pressure monitor in place. Assessment reveals an ICP reading of 66. What is the nurse's best action?
- A. Notify the physician
- B. Record the reading as the only action
- C. Turn the client and recheck the reading
- D. Place the client supine
Correct Answer: A
Rationale: An ICP of 66 mmHg is critically high (normal <20 mmHg), indicating severe brain swelling. Notifying the physician is urgent for immediate intervention.