Nokea
The nurse is beginning the shift and is assessing the oxygen exchange on a neonate. The nurse reviews the chart for pulse oximetry reading for the last 8 hours. The pulse oximetry reading at 3:30 p.m. is 75%. What should the nurse do first?
- A. Administer oxygen via mask.
- B. Swaddle the neonate in heated blankets.
- C. Reassess the oximetry reading in 30 minutes.
- D. Draw blood gases for oxygen and carbon dioxide levels.
Correct Answer: C
Rationale: A pulse oximetry reading of 75% is concerning but may be due to probe misplacement. Reassessing the reading first confirms accuracy before escalating to invasive measures like blood gases.
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The nurse is caring for a client post-total knee replacement. Which sign indicates a potential deep vein thrombosis?
- A. Calf swelling and pain
- B. Fever of 100°F (37.8°C)
- C. Mild incisional redness
- D. Joint stiffness
Correct Answer: A
Rationale: Calf swelling and pain are classic signs of deep vein thrombosis, a common postoperative complication requiring immediate evaluation.
A client has had sucralfate (Carafate) ordered as treatment for peptic ulcer disease. Which of the following statements indicates that the client understands how to take the medication?
- A. I should take the Carafate every evening at bedtime.'
- B. It is important that I take this drug on an empty stomach.'
- C. I should avoid milk products while taking this drug.'
- D. I should have my hemoglobin checked monthly while taking Carafate.'
Correct Answer: B
Rationale: Sucralfate should be taken on an empty stomach to coat the stomach lining effectively. Bedtime dosing, avoiding milk, or monthly hemoglobin checks are not required.
The nurse should instruct the parent of a child who is taking valproic acid (Depakene) that the child will need to have routine blood analyses consisting of which of the following?
- A. Complete blood count (CBC) and alkaline phosphate level.
- B. Amylase and platelet levels.
- C. Electrolytes and CBC.
- D. Platelet and fibrinogen levels.
Correct Answer: B
Rationale: Valproic acid requires monitoring of amylase (for pancreatitis) and platelet levels (for thrombocytopenia).
The mother of a newborn is voicing concerns about her baby's ability to hear. The nurse should tell the mother:
- A. Newborns cannot hear well until they are at least 6 weeks old.
- B. Her concern is unfounded because hearing problems are rare in newborns.
- C. The majority of states now mandate that newborns undergo a screening test for hearing.
- D. The mother can test the baby's hearing by clapping her hands 24 inches from the infant's head.
Correct Answer: C
Rationale: Most states mandate newborn hearing screening to detect issues early, addressing the mother's concern appropriately without dismissing it or suggesting unreliable home testing.
A client is prescribed risperidone. Which laboratory study should the nurse anticipate to be prescribed before the initiation of this medication therapy?
- A. Platelet count
- B. Blood clotting tests
- C. Liver function studies
- D. Complete blood count
Correct Answer: C
Rationale: Risperidone is an atypical antipsychotic medication that suppresses behavioral response in psychosis. Baseline assessment includes renal and liver function tests, and these studies should be done before the initiation of treatment. This medication is used with caution in clients with renal or hepatic impairment, clients with underlying cardiovascular disorders, and in older or debilitated clients. None of the other options are related to the administration of this medication.