Nokea
The nurse is caring for a newborn shortly after birth. Which of the following findings would be a priority to follow up?
- A. white, waxy substance in the axillae and labial folds
- B. edema of the scalp crossing the suture lines
- C. flat, bluish, discolored area on the buttocks
- D. small tuft of hair at the base of the spine
Correct Answer: D
Rationale: A tuft of hair at the spine base may indicate spina bifida occulta, requiring follow-up. Vernix, caput succedaneum, and Mongolian spots are normal newborn findings.
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A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client's temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is
- A. Maintain fluid and electrolyte balance
- B. Control nausea
- C. Manage pain
- D. Prevent urinary tract infection
Correct Answer: C
Rationale: Manage pain. The immediate goal of therapy is to alleviate the client's pain, which can be quite severe with kidney stones.
A client wanders away from home and is found 48 hours later sleeping on a park bench. The client is awake, alert, and oriented but cannot recall name, address, or events that occurred in the past 2 days. What is the priority nursing action?
- A. Contact family members
- B. Encourage the client to recall recent events
- C. Measure vital signs
- D. Monitor mental status
Correct Answer: C
Rationale: Measuring vital signs is the priority to ensure physiological stability in a client with amnesia, which may indicate a medical emergency like transient global amnesia.
The nurse has attended a staff education program about medication administration during pregnancy. Which of the following medications should the nurse recognize are contraindicated during pregnancy? Select all that apply.
- A. lisinopril
- B. albuterol
- C. isotretinoin
- D. doxycycline
- E. levothyroxine
Correct Answer: A,C,D
Rationale: Lisinopril (teratogenic), isotretinoin (severe birth defects), and doxycycline (fetal bone/teeth damage) are contraindicated. Albuterol and levothyroxine are generally safe.
The client has a chest tube attached to a portable water seal drainage system. Four hours after the chest tube is inserted, the nurse notes that there is no bubbling in the water seal compartment. What is the most likely explanation for this?
- A. The lung has reexpanded.
- B. There is an obstruction in the tubing coming from the pleural cavity.
- C. There is an air leak in the drainage system.
- D. The suction is not turned on.
Correct Answer: A
Rationale: No bubbling in the water seal four hours post-insertion suggests the lung has reexpanded, resolving the pneumothorax. Obstruction, air leaks, or inactive suction would typically cause other signs.
The nurse has just received report on 4 clients. Which of the following reported information is the most concerning?
- A. Client on a heparin drip with an activated PTT of 60 seconds
- B. Client reporting back pain 1 hour following coronary angiography
- C. Client with a head injury and a Glasgow Coma Scale score of 14
- D. Client with incisional pain rated as 6 on a scale of 0-10, two days after coronary artery bypass graft
Correct Answer: B
Rationale: Back pain shortly after coronary angiography may indicate retroperitoneal bleeding, a life-threatening complication requiring immediate investigation. The other conditions are less acute or expected.