Nokea
The nurse is assessing the newborn's respirations. Which of these findings would indicate a need for follow-up and further intervention?
- A. irregular respirations
- B. abdominal respirations
- C. shallow respirations
- D. 70 breaths per minute
Correct Answer: D
Rationale: The respirations in a newborn are usually irregular, abdominal, and shallow. However, the ideal respiratory rate in a newborn is 30-60 breaths per minute. A respiratory rate of 70 breaths per minute indicates tachypnea and may require intervention. The other answer choices do not necessarily indicate the need for follow-up.
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The nurse is providing instructions to the client taking alprazolam. Which substances should the client be instructed to avoid? Select all that apply.
- A. Alcohol
- B. Caffeine
- C. Narcotics
- D. Antioxidants
- E. Antihistamines
- F. Antidepressants
Correct Answer: A,C,E,F
Rationale: Alcohol, narcotics, antihistamines, and antidepressants can increase CNS side effects when taken with alprazolam (Xanax).
The nurse is initiating an IV infusion of lactated Ringer's (LR) for the client in shock. What is the purpose of LR for this client?
- A. Increase fluid volume and urinary output
- B. Draw water from the cells into the blood vessels
- C. Provide dextrose and nutrients to prevent cellular death
- D. Replace potassium and magnesium for cardiac stabilization
Correct Answer: A
Rationale: A: LR is an isotonic crystalloid solution containing multiple electrolytes in approximately the same concentration as plasma. It enters the cells from the blood, provides fluids, and increases urinary output. B: A hypertonic solution draws fluid from the cells into the vascular compartment; LR is isotonic. C: LR alone does not contain dextrose. Formulations with dextrose are available. D: Magnesium is not a component of LR.
The client who is to receive a scheduled dose of digoxin has an irregular apical pulse at 92 bpm and a serum potassium of 3.9 mEq/L. Which nursing documentation reflects the most appropriate action?
- A. Serum potassium level WNL. Digoxin given for rapid apical pulse.
- B. Digoxin withheld because the client's apical heart rate is irregular.
- C. Digoxin withheld to prevent toxicity due to the low potassium level.
- D. HCP informed of irregular heart rate and low serum potassium level.
Correct Answer: A
Rationale: A: A normal serum potassium level is 3.5 to 5.0 mEq/L. Digoxin (Lanoxin), a cardiac glycoside, slows and strengthens the heart. It is used for rate control in clients with atrial fibrillation, which often produces an irregular rhythm. B: Dysrhythmias can occur if digoxin is given when the serum potassium level is low, but the serum potassium level is WNL. Digoxin is used for rate control and would not be withheld due to an irregular HR. C: Although it is important to monitor for digoxin toxicity, the serum potassium level is WNL. D: Withholding digoxin and notifying the HCP are unnecessary; the serum potassium is WNL.
The nurse receives shift report for five clients, and all are taking lithium. Place the clients in the order of priority.
- A. The client who has a dry mouth, headache, and thirst
- B. The client who has a fever, rash, and the start of hives
- C. The client who has blurred vision, ataxia, and tinnitus
- D. The client who has mild hand tremors, nausea, and vomiting
- E. The client who has had increasing confusion, nystagmus, and just had a seizure
Correct Answer: E,C,B,D,A
Rationale: Clients with severe lithium toxicity (E), signs of toxicity (C), allergic reactions (B), side effects needing evaluation (D), and manageable side effects (A) are prioritized in that order.
The client using latanoprost eye drops for treatment of glaucoma calls the ophthalmology clinic after noting a brown pigmentation of the iris. Which nursing action is most appropriate?
- A. Instruct the client to come to the clinic to have the eyes and medication evaluated.
- B. Schedule an appointment for the client to see an internist for liver function studies.
- C. Tell the client that the pigmentation is from the latanoprost but will eventually regress.
- D. Recommend that the client wear sunglasses when outdoors to decrease iris pigmentation.
Correct Answer: A
Rationale: A: A side effect of latanoprost (Xalatan), a prostaglandin, includes a heightened brown pigmentation of the iris, which stops progressing when latanoprost is discontinued. B: Jaundiced sclera, and not brown iris pigmentation, would suggest the need to evaluate liver function. C: The brown iris pigmentation from the latanoprost does not usually regress. D: Wearing sunglasses will have no effect on the iris pigmentation.