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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Based on knowledge of cultural diversity, the nurse knows that obtaining a CBC will be most distressing for the client who is:
- A. Asian
- B. African-American
- C. Latino
- D. Native American
Correct Answer: D
Rationale: Some Native American cultures believe blood removal weakens the body or spirit, making a CBC distressing. Other groups typically do not have this belief.
The nurse is caring for several hospitalized children with the following diagnoses. Which disorder is likely to result in metabolic acidosis?
- A. Severe diarrhea for 24 hours
- B. Nausea with anorexia
- C. Alternating constipation and diarrhea
- D. Vomiting for over 48 hours
Correct Answer: A
Rationale: Severe diarrhea is the only problem listed that can lead to metabolic acidosis if untreated.
Laboratory results
Glucose (fasting)
70-110 mg/dL
(3.9-6.1 mmol/L)
180 mg/dL
(10.0 mmol/L)
The nurse is preparing to administer insulin aspart subcutaneously at 0700 to a client with type 1 diabetes mellitus. Which of following actions would be a priority for the nurse to take?
- A. Choose a site on the clients arm for the injection
- B. Give the client breakfast within 15 minutes
- C. Recheck the capillary blood glucose level in 1 hour
- D. Reinforce teaching about signs and symptoms of hyperglycemia
Correct Answer: B
Rationale: Insulin aspart is rapid-acting, peaking within 1-3 hours. Administering it at 0700 requires breakfast within 15 minutes to prevent hypoglycemia. Site selection is routine, rechecking glucose later is secondary, and teaching is not urgent.
The nurse is caring for a client who has a pulmonary embolism. Which of the following findings would the nurse expect to observe? Select all that apply.
- A. dyspnea
- B. chest pain
- C. tachypnea
- D. hypoxemia
- E. bradycardia
- F. tracheal deviation
Correct Answer: A,B,C,D
Rationale: Pulmonary embolism obstructs pulmonary arteries, causing dyspnea, chest pain, tachypnea, and hypoxemia. Bradycardia is unlikely; tachycardia is typical. Tracheal deviation is associated with tension pneumothorax, not embolism.
The doctor has ordered Lovenox (enoxaparin) 20 mg subcutaneously daily. The medication is available as 60 mg per mL. The nurse should administer:
- A. 0.50 mL
- B. 0.53 mL
- C. 0.33 mL
- D. 0.25 mL
Correct Answer: C
Rationale: Calculate: 20 mg ÷ 60 mg/mL = 0.333 mL, rounded to 0.33 mL for accurate dosing of Lovenox.