Nokea
Laboratory reference ranges
Hematocrit
39%-59%
(0.39-0.59)
The nurse is collecting data from a 2-week-old client who has tetralogy of Fallot. Which of the following findings would be a priority to follow up?
- A. cyanosis resolves in the knee-chest position
- B. weight gain of 0.6 lb (0.27 kg) since birth
- C. hematocrit level of 67% (0.67)
- D. murmur noted on auscultation
Correct Answer: C
Rationale: Elevated hematocrit indicates polycythemia, a serious complication of tetralogy of Fallot. Knee-chest relief , weight gain , and murmurs are expected.
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An adult is admitted with a pneumothorax following an accident. Immediately after insertion of a chest tube, the client says to the nurse, 'Why do I have a tube in my chest and that thing hanging on the side of the bed? I don't like it.' What should the nurse include when replying to the client?
- A. Tell the client that the chest tube helps the client take bigger breaths
- B. Focus on the client's feelings
- C. Explain that the chest tube will remove air and/or fluid from the pleural cavity and allow the lung to reexpand
- D. Tell the client that the nurse will contact the physician to have it removed
Correct Answer: C
Rationale: The chest tube drains air/fluid from the pleural space, allowing lung re-expansion in pneumothorax, providing an accurate, educational response to the client's question.
The nurse reinforces discharge teaching for the parent of a child newly prescribed methylphenidate for attention-deficit hyperactivity disorder. The nurse advises the parent that the child might experience which side effects?
- A. Decreased blood pressure and growth delays
- B. Heart palpitations and weight gain
- C. Loss of appetite and restlessness
- D. Trouble sleeping and a dry cough
Correct Answer: C
Rationale: Methylphenidate commonly causes loss of appetite and restlessness . Hypotension , palpitations/weight gain , and cough are less typical.
The nurse has received a prescription from the health care provider to administer 94 mg of methylprednisolone via IV push. The available vial contains 125 mg in 2 mL. Select the syringe containing the appropriate amount of medication to be administered.
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: C
Rationale: Calculate: 94 mg ÷ 125 mg/2 mL = 1.504 mL. Syringe 3 (typically 1.5 mL) is closest. Syringes 1, 2, and 4 are not specified but assumed incorrect volumes.
The registered nurse (RN) is making decisions regarding client room assignments on a pediatric unit. Which possible roommate would be most appropriate for a 3 year-old child with minimal change nephrotic syndrome?
- A. 2 year-old with respiratory infection
- B. 3 year-old fracture whose sibling has chickenpox
- C. 4 year-old with bilateral inguinal hernia repair
- D. 6 year-old with a sickle cell anemia crisis
Correct Answer: C
Rationale: Children with nephrotic syndrome are at high risk for development of infections as a result of the standard use of immunosuppressant therapy, as well as from the accumulation of fluid (edema). Therefore, these children must be protected from sources of possible infection.
The nurse is reinforcing teaching about newly prescribed clonidine for a client with hypertension. Which of the following information would be most important for the nurse to reinforce?
- A. Avoid consuming high-sodium foods
- B. Do not stop taking the medication abruptly
- C. Limit alcohol intake while taking the medication
- D. Use an oral moisturizer to relieve dry mouth
Correct Answer: B
Rationale: Abruptly stopping clonidine can cause rebound hypertension, a critical risk. Sodium , alcohol , and dry mouth are less urgent.