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The nurse is caring for a client who has acute pericarditis. Which of the following findings would be a priority to follow up?
- A. chest pain that is worse with deep inspiration
- B. muffled heart tones and jugular venous distension
- C. pericardial friction rub auscultated at the left sternal border
- D. temperature of 100.7 F (38.2 C) and a nonproductive cough
Correct Answer: B
Rationale: Muffled heart tones and jugular venous distension (B) suggest pericardial effusion or tamponade, a life-threatening complication requiring urgent follow-up. Chest pain (A) and friction rub (C) are expected, and mild fever (D) is less urgent.
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A non-stress test has been ordered for a pregnant client with diabetes mellitus. Non-stress testing is a part of the diabetic's prenatal care because:
- A. Fetal movement is adversely affected by diabetes.
- B. Maternal insulin levels can have a negative effect on fetal energy.
- C. Diabetes can adversely affect development of placental vessels.
- D. Fetal lung maturity is most easily determined by non-stress testing.
Correct Answer: C
Rationale: Diabetes can impair placental vessel development, reducing oxygen and nutrient delivery to the fetus, necessitating non-stress testing to monitor fetal well-being. Fetal movement and lung maturity are assessed differently, and insulin's effect is indirect.
A client with acquired immunodeficiency syndrome is admitted for treatment of wasting syndrome. Which of the following dietary modifications can be used to compensate for the limited absorptive capability of the intestinal tract?
- A. Thoroughly cooking all foods
- B. Offering yogurt and buttermilk between meals
- C. Forcing fluids
- D. Providing small, frequent meals
Correct Answer: D
Rationale: Small, frequent meals are easier to digest and absorb, compensating for the limited absorptive capacity in wasting syndrome. Cooking foods thoroughly reduces infection risk but doesn't aid absorption. Yogurt and buttermilk may not be tolerated, and forcing fluids addresses hydration, not absorption.
An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN?
- A. A middle-aged client who says 'I took too many diet pills' and 'my heart feels like it is racing out of my chest.'
- B. A young adult who says 'I hear songs from heaven. I need money for beer. I quit drinking 2 days ago for my family. Why are my arms and legs jerking?'
- C. An adolescent who was recently diagnosed with leukemia and started chemotherapy with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10
- D. An elderly client who reports having taken a 'large crack hit' 10 minutes prior to walking into the emergency room
Correct Answer: C
Rationale: Nurses who are floated to other units should be assigned to a client who has minimal anticipated immediate complications of their problem. The client in option C exhibits opioid toxicity with the pinpoint pupils and has the least risk of complications occurring in the near future.
The practical nurse is performing a physical examination with the registered nurse on a 2-year-old with cold symptoms and a fever at home of 101.7 F (38.7 C). Which interventions will enhance the child's cooperation during the examination? Select all that apply.
- A. Allow the child to play with the stethoscope
- B. Begin with the child in the parent's lap
- C. Interact with the parent in a friendly manner
- D. Play with the child using a finger puppet
- E. Start by taking the child's vital signs
Correct Answer: A,B,C,D
Rationale: Playing with the stethoscope (A), starting in the parent's lap (B), friendly interaction (C), and using a puppet (D) reduce anxiety and enhance cooperation. Vital signs (E) may distress the child if done first.
The nurse is caring for an infant who has a prescription for amoxicillin 25 mg/kg/day in 2 divided doses. The client weighs 16.5 lb (7.5 kg). The nurse has amoxicillin oral suspension 125 mg/5 mL available. How many mL should the nurse administer to the client with each dose? Record your answer using 2 decimal places.
Correct Answer: 3.75 mL/dose
Rationale: Calculation: 7.5 kg × 25 mg/kg/day = 187.5 mg/day. Divided into 2 doses = 93.75 mg/dose. 125 mg/5 mL = 25 mg/mL. 93.75 mg ÷ 25 mg/mL = 3.75 mL/dose (A).