Nokea
The nurse is caring for the patient following removal of a large posterior oral lesion. The priority nursing measure would be to:
- A. Maintain a patent airway
- B. Perform meticulous oral care every 2 hours
- C. Ensure that the incisional area is kept as dry as possible
- D. Assess the client frequently for pain
Correct Answer: A
Rationale: Maintaining a patent airway is critical post-oral surgery due to the risk of swelling or bleeding obstructing the airway.
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The nurse must administer 120 mg of amoxicillin oral suspension to a child. However, the only dosage available in the pharmacy is 200 mg per 5 mL. How many milliliters of suspension should the nurse administer? Record your answer using a whole number only.
Correct Answer: 3
Rationale: Dose = 120 mg, concentration = 200 mg/5 mL = 40 mg/mL. Volume = 120 m/40 mg/mL = 3 mL.
A client is admitted to the hospital with a temperature of 99.8°F, complaints of blood-tinged hemoptysis, fatigue, and night sweats. The client's symptoms are consistent with a diagnosis of:
- A. Pneumonia
- B. Reaction to antiviral medication
- C. Tuberculosis
- D. Superinfection due to low CD4 count
Correct Answer: C
Rationale: The symptoms of low-grade fever, blood-tinged hemoptysis, fatigue, and night sweats are classic for tuberculosis.
The nurse is responsible for performing a neonatal assessment on a fullterm infant. At 1 minute, the nurse could expect to find:
- A. An apical pulse of 100
- B. An absence of tonus
- C. Cyanosis of the feet and hands
- D. Jaundice of the skin and sclera
Correct Answer: C
Rationale: Acrocyanosis (cyanosis of hands and feet) is normal in newborns at 1 minute due to immature circulation.
An obstetrical client with diabetes has an amniocentesis at 28 weeks gestation. Which test indicates the degree of fetal lung maturity?
- A. Alpha-fetoprotein
- B. Estriol level
- C. Indirect Coomb's
- D. Lecithin sphingomyelin ratio
Correct Answer: D
Rationale: The lecithin-sphingomyelin (L/S) ratio assesses fetal lung maturity by measuring surfactant levels, critical for preterm delivery planning in diabetic pregnancies.
A client is hospitalized with an acute myocardial infarction. Which nursing diagnosis reflects an understanding of the cause of acute myocardial infarction?
- A. Decreased cardiac output related to damage to the myocardium
- B. Impaired tissue perfusion related to an occlusion in the coronary vessels
- C. Acute pain related to cardiac ischemia
- D. Ineffective breathing patterns related to decreased oxygen to the tissues
Correct Answer: B
Rationale: Impaired tissue perfusion due to coronary occlusion is the primary cause of acute myocardial infarction.