Nokea
The nurse is caring for a newborn who is on strict intake and output. The used diaper weighs $73.5 \mathrm{gm}$. The diaper's dry weight was $62 \mathrm{gm}$. The newborn's urine output is:
- A. 10 ml
- B. 11.5 ml
- C. 10 gm
- D. 12 gm
Correct Answer: B
Rationale: Urine output is calculated by subtracting dry diaper weight from wet diaper weight: 73.5 gm - 62 gm = 11.5 ml (1 gm = 1 ml for urine).
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A client has had a recent below-knee (BK) amputation of the right leg because of a traumatic injury. After removing the elastic wrap, which the client had applied, the nurse notes an unusual pattern of swelling. Which of the following is the most likely reason for this observation?
- A. Wound infection
- B. Impaired circulation to the stump
- C. Incorrect wrap technique
- D. Bleeding into the tissues
Correct Answer: C
Rationale: An unusual swelling pattern after removing an elastic wrap suggests incorrect wrap technique (C), which can cause uneven pressure. Infection (A), impaired circulation (B), or bleeding (D) would present differently.
A client elects to have epidural anesthesia to relieve the discomfort of labor. Following the initiation of epidural anesthesia, the nurse should give priority to:
- A. Checking for cervical dilation
- B. Placing the client in a supine position
- C. Checking the client's blood pressure
- D. Obtaining a fetal heart rate
Correct Answer: C
Rationale: Epidural anesthesia can cause hypotension, making blood pressure monitoring a priority.
A nurse prepares to administer a transfusion of RBCs and takes the client's vital signs. The client's temperature is 102.7°F, but other vitals are within normal limits. The nurse should
- A. transfuse the RBC as ordered.
- B. administer an antipyretic and transfuse the RBCs.
- C. transfuse the RBCs but monitor the temperature hourly.
- D. not transfuse the RBCs and instead contact the physician.
Correct Answer: D
Rationale: Fever (102.7°F) may indicate an infection or transfusion reaction risk. The physician should be contacted before proceeding with the transfusion.
The nurse is caring for a client with rheumatoid arthritis. The nurse knows that the client's symptoms will be most improved by:
- A. Taking a warm shower upon awakening
- B. Applying ice packs to the joints
- C. Taking two aspirin before going to bed
- D. Going for an early morning walk
Correct Answer: A
Rationale: A warm shower reduces morning stiffness in rheumatoid arthritis by improving joint mobility and reducing inflammation.
The RN is making assignments for the day. Which one of the following duties can be assigned to the unlicensed assistive personnel?
- A. Notifying the physician of an abnormal lab value
- B. Providing routine catheter care with soap and water
- C. Administering two aspirin to a client with a headache
- D. Setting the rate of an infusion of normal saline
Correct Answer: B
Rationale: Unlicensed assistive personnel can perform routine catheter care, a non-invasive task within their scope.