Nokea
The nurse is calculating a client's intake and output for the shift. How many mL should the nurse record as the client's output?
Correct Answer: 208
Rationale: Emesis (120 mL) plus diaper output (50-30=20 mL, 52-30=22 mL, 46-30=16 mL) totals 120+20+22+16=208 mL.
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The mother of a 1-week-old infant says to the nurse, 'When will that ugly black cord thing come off?' How should the nurse reply?
- A. Are you wiping it with alcohol each time you change the baby's diaper?'
- B. It usually comes off in 10 days to three weeks.'
- C. It sounds as if it bothers you. Would you like to talk about it?'
- D. It should be off by now. I'll have the doctor check to be sure there is no problem.'
Correct Answer: B
Rationale: The umbilical cord typically detaches in 10 days to 3 weeks, providing accurate information. Other responses are irrelevant or incorrect.
Two people call in sick on the medical-surgical unit and no additional help is available. The team consists of an RN, an LPN and an unlicensed assistive personnel (UAP). Which of these activities should the nurse assign to the UAP?
- A. Assist with plans for any clients discharged
- B. Provide basic hygiene care to all clients on the unit
- C. Assess a client after an acute myocardial infarction
- D. Gather the vital signs of all clients on the unit
Correct Answer: B
Rationale: Basic client care, which is routine, should be delegated to a UAP since the unit is short on help. The vital signs can be done by the RN and PN as they make rounds since this data is more critical to making decisions about the care of the clients.
The nurse is observing continuous cardiac monitoring for assigned clients. Which of the following cardiac rhythms would immediate follow-up?
Correct Answer: C
Rationale: Ventricular fibrillation (VF) is a lethal dyshythmia characterized by disorganized electrical activity in the heart ventricles. Because
of this erratic electrical activity, the heart muscles lose the ability to contract, resulting in loss of blood flow and pulse (ie, cardiac
arrest). Nurses who identify a client with VF should immediately check the pulse, start CPR, and prepare the client for defibrillation
A 2 year-old child has recently been diagnosed with cystic fibrosis. The nurse is teaching the parents about home care for the child. Which of the following information is appropriate for the nurse to include?
- A. Allow the child to continue normal activities
- B. Schedule frequent rest periods
- C. Limit exposure to other children
- D. Restrict activities to inside the house
Correct Answer: A
Rationale: Allow the child to continue normal activities. Physical activity supports autonomy and mucus secretion in cystic fibrosis.
The best choice for the child following a tonsillectomy is:
- A. Fruit punch
- B. Grape soda
- C. A banana Popsicle
- D. Ice cream
Correct Answer: C
Rationale: A banana Popsicle is soothing, cold, and non-irritating to the surgical site. Liquids like punch or soda may sting, and ice cream is dairy, which can increase mucus.