Nokea
The nurse is caring for a newborn with jaundice who is being treated with phototherapy. What action by the nurse would require the charge nurse to intervene?
- A. Allowing the parents to feed the newborn
- B. Applying a shirt while the client is exposed to phototherapy
- C. Covering the client's eyes with protective shields
- D. Monitoring the temperature of the incubator while the newborn is inside
Correct Answer: B
Rationale: Clothing during phototherapy reduces skin exposure to light, decreasing treatment efficacy.
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The home health nurse prepares to give benztropine to a 70-year-old client with Parkinson disease. Which client statement is most concerning and would warrant notification of the supervising registered nurse?
- A. I am going for repeat testing to confirm glaucoma.
- B. I am not able to exercise as much as I used to.
- C. I started taking esomeprazole for heartburn.
- D. My bowel movements are not regular.
Correct Answer: A
Rationale: Benztropine can increase intraocular pressure, worsening glaucoma, and requires immediate follow-up.
The pediatric nurse receives report on 4 clients. Which client should the nurse see first?
- A. A 2-month-old awaiting evaluation for possible hip dislocation; parents are at the bedside
- B. A 6-year-old just returned from a bronchoscopy; a parent is at the bedside
- C. A 7-year-old just returned from a non-contrast abdominal CT scan; no parents are at the bedside
- D. An 11-year-old scheduled for ear surgery today, no parents are at the bedside
Correct Answer: B
Rationale: The 6-year-old post-bronchoscopy is at risk for airway complications and requires immediate assessment.
The nurse is assisting with the admission of a client who had a nephrectomy 6 hours ago. The client should be assigned to a semiprivate room with a client who has
- A. a pulmonary embolism, is receiving heparin therapy, and has a decreased platelet count
- B. cellulitis of the leg, is receiving antibiotic therapy, and is reporting loose stools
- C. type 1 diabetes mellitus, a wound on the foot, and an elevated temperature
- D. HIV infection, a decreased CD4+ cell count, and is reporting fatigue
Correct Answer: B
Rationale: The client with cellulitis and loose stools is least likely to pose an infection risk to the post-nephrectomy client, who is at risk for infection due to recent surgery. Other options involve conditions with higher infection risks or bleeding concerns.
The nurse is teaching the parent of a 6-year-old client about sleep. Which of the following information should the nurse include? Select all that apply.
- A. Your child should sleep 9 to 12 hours every night.
- B. As your child grows, the hours of required sleep increase.
- C. Encourage active play before bedtime to promote restful sleep.
- D. Avoid giving your child large amounts of liquid after dinnertime.
- E. It is important to establish and maintain a regular bedtime routine.
Correct Answer: A,D,E
Rationale: Children aged 6 need 9-11 hours of sleep, limited liquids prevent bedwetting, and routines promote sleep. Sleep needs decrease with age, and active play close to bedtime may disrupt sleep.
The nurse is caring for a client who is having a thoracentesis. Following the procedure, the nurse monitors for complications. The initial post-procedure monitoring plan should include what? Select all that apply.
- A. Level of alertness
- B. Lung sounds
- C. Oxygen saturation
- D. Respiratory pattern
- E. Temperature
- F. Urine output
Correct Answer: A,B,C,D
Rationale: Monitoring alertness, lung sounds, oxygen saturation, and respiratory pattern detects complications like pneumothorax or respiratory distress.