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The nurse is caring for a neonate with an infection. The nurse would be MOST concerned if which of the following was observed?
- A. Heart rate of 150 bpm.
- B. Axillary temperature of 96°F (35.5°C).
- C. Weight increase of 4 oz.
- D. Respiratory rate of 65 at rest.
Correct Answer: D
Rationale: A respiratory rate of 65 at rest (normal 30–50) indicates tachypnea, suggesting sepsis or hypoxia. Options A, B, and C are less concerning.
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A client with paralysis from a cerebrovascular accident (CVA).
Which of the following is a priority nursing goal in the plan of care for a client with paralysis from a cerebrovascular accident (CVA)?
- A. Maintain adduction of the affected shoulder.
- B. Prevent flexion of the affected extremities.
- C. Observe active range of motion (ROM) daily to all extremities.
- D. Maintain external rotation of the affected hip.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) to prevent deformities, the nurse needs to prevent adduction of the affected shoulder (2) correct-flexor muscles are stronger than extensor muscles (3) client will be unable to perform active ROM, will need assistance from nurse (4) to prevent deformities, the nurse needs to prevent external rotation of the hip joint, prevent foot drop (plantar flexion), and place the hand in slight supination so that the fingers are barely flexed
The nurse performs diet teaching for a client with a spinal cord injury at S-3. Which of the following meals, if chosen by the client, would indicate to the nurse that teaching has been effective?
- A. Cheeseburger with tomato and onion.
- B. Spaghetti with meat sauce and green beans.
- C. Tuna fish sandwich with orange juice.
- D. Grilled cheese sandwich and chocolate pudding.
Correct Answer: B
Rationale: Spaghetti with meat sauce and green beans is high-fiber and low-fat, preventing constipation in spinal cord injury. Options A, C, and D are higher in fat or lower in fiber.
The nurse is caring for a client with a history of spinal cord injury.
- A. Which intervention is most effective for preventing autonomic dysreflexia in a client with a spinal cord injury?
- B. Monitor blood pressure regularly.
- C. Administer analgesics for pain.
- D. Keep the bladder empty.
- E. Encourage a low-fiber diet.
Correct Answer: C
Rationale: Keeping the bladder empty prevents distension, a common trigger for autonomic dysreflexia, a life-threatening hypertensive crisis in spinal cord injury. Blood pressure monitoring detects it, analgesics are irrelevant, and high-fiber diets prevent constipation.
The nurse is caring for a client who is postoperative day 1 after a total hip replacement. Which of the following actions should the nurse prioritize?
- A. Encourage early ambulation.
- B. Administer pain medication as needed.
- C. Keep the affected leg in adduction.
- D. Monitor the incision for drainage.
Correct Answer: A
Rationale: Early ambulation prevents complications like thrombosis and promotes recovery. Options B, C, and D are secondary or incorrect.
A newborn has hyperbilirubinemia and is undergoing phototherapy with a fiberoptic blanket. Which safety measure is most important during this process?
- A. Regulate the neonate's temperature using a radiant heater
- B. Withhold feedings while under the phototherapy
- C. Provide water feedings at least every 2 hours
- D. Protect the eyes of neonate from the phototherapy lights
Correct Answer: C
Rationale: Provide water feedings at least every 2 hours. Protecting the eyes of the neonates is very important to prevent damage when under the ultraviolet lights, but since the blanket is used, extra protection of the eyes is unnecessary. It is recommended that the neonate remain under the lights for extended periods. The neonate's skin is exposed to the light and the temperature is monitored, but a heater may not be necessary. There is no reason to withhold feedings. Frequent water or feedings are given to help with the excretion of the bilirubin in the stool.