Nokea
The nurse is caring for a four-year-old child with a closed head injury. The nurse would be reassured by which of the following observations?
- A. The child is able to state his name when asked who he is.
- B. The child reaches for a stuffed animal brought from home.
- C. The child maintains himself in opisthotonos.
- D. The child withdraws from mildly painful stimuli.
Correct Answer: A
Rationale: Stating his name indicates orientation, a positive sign post-head injury. Options B, C, and D are less reassuring: reaching for a toy is nonspecific, opisthotonos suggests meningeal irritation, and withdrawal may occur in unconscious states.
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A client is scheduled to undergo a bone marrow aspiration. Which position would the nurse assist the client into for this procedure?
- A. Dorsal recumbent
- B. Supine
- C. High Fowler's
- D. Lithotomy
Correct Answer: A
Rationale: The dorsal recumbent position is used for bone marrow aspiration, typically performed on the iliac crest, allowing access and patient comfort. Supine, High Fowler's, and lithotomy positions are not suitable, so B, C, and D are incorrect.
The nurse auscultates bibasilar inspiratory crackles in a newly admitted 68 year-old client with a diagnosis of congestive heart disease. Which other finding is most likely to occur?
- A. Chest pain
- B. Peripheral edema
- C. Nail clubbing
- D. Lethargy
Correct Answer: B
Rationale: Peripheral edema. Bibasilar crackles and peripheral edema are common in congestive heart failure due to fluid overload.
A diabetic client asks the nurse why the provider ordered a glycosylated hemoglobin (HbA) measurement, since a blood glucose reading was just performed. You will explain to the client that the HbA test:
- A. Provides a more precise blood glucose value than self-monitoring
- B. Is performed to detect complications of diabetes
- C. Measures circulating levels of insulin
- D. Reflects an average blood sugar for several months
Correct Answer: D
Rationale: Glycosylated hemoglobin values reflect the average blood glucose (hemoglobin-bound) for the previous 2-3 months and can be used to monitor client adherence to the therapeutic regimen.
A nurse performing actions that would be considered negligence.
Which of the following actions, if performed by the nurse, would be considered negligence?
- A. Obtaining a Guthrie Blood Test on a four-day-old infant.
- B. Massaging lotion on the abdomen of a three-year-old diagnosed with Wilm's tumor.
- C. Instructing a five-year-old asthmatic to blow on a pinwheel.
- D. Playing kickball with a 10-year-old with juvenile arthritis (JA).
Correct Answer: B
Rationale: Strategy: 'Would be considered negligence' indicates an incorrect action. (1) obtain after ingestion of protein, no later than 7 days after delivery (2) correct-manipulation of mass may cause dissemination of cancer cells (3) this exercise extends expiratory time and increases expiratory pressure (4) excellent moving and stretching exercise
The nurse is caring for a client who is receiving IV gentamicin for a gram-negative infection. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Creatinine 2.5 mg/dL.
- B. Sodium 140 mEq/L.
- C. Potassium 4.0 mEq/L.
- D. Hemoglobin 13 g/dL.
Correct Answer: A
Rationale: A creatinine of 2.5 mg/dL indicates renal impairment, a serious complication of gentamicin due to nephrotoxicity, requiring immediate evaluation. Options B, C, and D are normal: sodium 140 mEq/L, potassium 4.0 mEq/L, and hemoglobin 13 g/dL do not indicate complications.