Nokea
The nurse is caring for a preterm neonate in the NICU. Which intervention is essential to prevent retinopathy of prematurity?
- A. Monitor oxygen saturation
- B. Administer vitamin D
- C. Provide high-calorie formula
- D. Keep the incubator at 37°C
Correct Answer: A
Rationale: Excessive oxygen can contribute to retinopathy of prematurity in preterm neonates. Monitoring oxygen saturation ensures levels remain within a safe range.
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The best way to objectively evaluate the effectiveness of an individual staff member's time management skills in a longitudinal manner is to:
- A. Observe the staff member during an entire shift of duty to determine whether or not the nurse has accurately and appropriately established priorities.
- B. Observe the staff member during an entire shift of duty to determine whether or not the nurse has accurately and appropriately completed priority tasks.
- C. Ask the staff member how they feel like they have been able to employ their time management skills for the last six months.
- D. Collect outcome data over time and then aggregate and analyze this data to determine whether or not the staff member has completed reasonable assignments in the allotted time before the end of their shift of duty.
Correct Answer: D
Rationale: To objectively evaluate time management skills over time, collecting, aggregating, and analyzing outcome data provides a longitudinal perspective on whether the staff member consistently completes assignments within the allotted time. This method is more objective than single-shift observations (A, B) or self-reports .
In the early postoperative period, the nurse notes a bright red, 3' x 5' area of drainage on the client's abdominal laparotomy dressing. What should be the nurse's first action in response to this observation?
- A. Ignore it because drainage is normal.
- B. Increase the I.V. flow rate.
- C. Take the client's vital signs.
- D. Change the dressing.
Correct Answer: C
Rationale: Bright red drainage suggests active bleeding, so taking vital signs to assess for hemodynamic instability is the priority.
Your pregnant client has a new order for a medication. What principle should you apply to this new medication?
- A. The fact that drugs classified as categories C, D and X are contraindicated for women who are pregnant.
- B. The fact that drugs classified as categories A, B and C are contraindicated for women who are pregnant.
- C. The fact that drugs classified as categories C, D and E are contraindicated for women who are pregnant.
- D. The fact that drugs classified as categories C, D and Z are contraindicated for women who are pregnant.
Correct Answer: A
Rationale: Drugs in FDA pregnancy categories C, D, and X carry risks (potential harm, known harm, or absolute contraindication, respectively) and are generally contraindicated in pregnancy unless benefits outweigh risks.
A client with the diagnosis of Bell's palsy is distressed about the change in facial appearance. Which characteristic of Bell's palsy should the nurse tell the client about to help the client cope with the disorder?
- A. It usually resolves when treated with vasodilator medications.
- B. It is similar to stroke, but all symptoms will go away eventually.
- C. It is not caused by stroke, and many clients recover in 3 to 5 weeks.
- D. It is not caused by a tumor, and many clients recover in 3 to 5 weeks.
Correct Answer: C
Rationale: Clients with Bell's palsy should be reassured that they have not experienced a stroke and that symptoms often disappear spontaneously in approximately 3 to 5 weeks. The client is given supportive treatment for symptoms; the treatment does not involve administering vasodilators. Bell's palsy is not usually caused by a tumor. While option D is factually correct, option C directly addresses the client's distress by clarifying the distinction from a stroke, which is a common concern due to facial paralysis, making it the most appropriate response for coping.
A client has atrial fibrillation. The nurse should monitor the client for:
- A. Cardiac arrest
- B. Cerebrovascular accident
- C. Heart block
- D. Ventricular fibrillation
Correct Answer: B
Rationale: Atrial fibrillation increases the risk of thromboembolism, leading to cerebrovascular accident (stroke). Cardiac arrest, heart block, and ventricular fibrillation are less directly associated.