Nokea
The nurse is collecting data from assigned clients. It would require follow-up if a
- A. 3-week-old client has an anterior fontanel that pulsates slightly and bulges when crying
- B. 4-week-old client has a posterior fontanel that is soft and flat to palpation
- C. 6-month-old client had a birth weight of 7 lb 3 oz (3300 g) and now weighs 12 lb (5400 g)
- D. 12-month-old client had a birth weight of 6 lb 4 oz (2800 g) and now weighs 19 lb 2 oz (8700 g)
Correct Answer: C
Rationale: A 6-month-old weighing only 12 lb (5400 g) from a birth weight of 7 lb 3 oz (3300 g) indicates failure to thrive, requiring follow-up. Other findings (fontanels, 12-month-old weight) are within normal ranges.
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Which of the following medications would be least helpful for a client who is experiencing an acute attack of bronchial asthma?
- A. Cromolyn Sodium (Intal)
- B. Epinephrine (Epi-Pen)
- C. Metaproterenol (Alupent)
- D. Theophylline (Theolair)
Correct Answer: A
Rationale: Cromolyn sodium prevents asthma attacks but is not effective for acute attacks. Epinephrine, metaproterenol, and theophylline provide rapid bronchodilation.
The nurse is reinforcing education about lifestyle modifications for a client newly diagnosed with Meniere disease. Which statement by the client indicates a need for further teaching?
- A. I need to enroll in a smoking cessation program.
- B. I need to restrict the amount of potassium in my diet.
- C. I will lie down and avoid walking unassisted during acute attacks.
- D. I will limit the amount of caffeine and alcohol that I consume.
Correct Answer: B
Rationale: Restricting potassium isn't indicated for Ménière's disease; a low-sodium diet is typically recommended to reduce fluid retention. Smoking cessation, lying down during attacks, and limiting caffeine/alcohol are appropriate.
The nurse is caring for a client with Cushing's syndrome. The nurse should carefully assess the client for signs of:
- A. Hypoglycemia
- B. Infection
- C. Hypovolemia
- D. Hyperinsulinemia
Correct Answer: B
Rationale: Cushing's syndrome causes immunosuppression, increasing infection risk . Hypoglycemia , hypovolemia , and hyperinsulinemia are not primary concerns.
The nurse is observing a nursing assistant transfer a client from bed to chair. Which observation needs correction? Select all that apply.
- A. The nursing assistant lowers the bed before starting the procedure.
- B. The nursing assistant sits the client on the side of the bed before assisting the client to move.
- C. The nursing assistant stands with feet close together and knees and back straight when helping the client to move.
- D. The nursing assistant asks the client to grab the arm of the nursing assistant during the transfer.
- E. The nursing assistant lifts the client up by tugging on the client's arms.
- F. The nursing assistant assists the client to stand and pivot to get into the chair.
Correct Answer: C,D,E
Rationale: The nursing assistant should stand with feet apart and knees bent to prevent injury, not grab the client's arm, and avoid tugging on the client's arms. Lowering the bed, sitting the client up, and assisting to pivot are correct.
The physician has ordered an irrigation of the client's left ear for the removal of cerumen. To prevent vestibular stimulation, the fluid should be degrees Fahrenheit:
- A. 68
- B. 76
- C. 98
- D. 120
Correct Answer: C
Rationale: Cerumen is removed using a mixture of water and hydrogen peroxide at body temperature. Answers A and B are incorrect because they are too cold. Answer D is incorrect because it is too hot.