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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The nurse is monitoring a client who is going through barbiturate withdrawal. Which symptom is of most concern to the nurse?
- A. Nausea and vomiting
- B. Anxiety
- C. Hallucinations
- D. Seizures
Correct Answer: D
Rationale: Seizures in barbiturate withdrawal are life-threatening, requiring immediate intervention, unlike nausea, anxiety, or hallucinations.
A 12-month-old client has a high blood lead level of 18 mcg/dL. The nurse is reinforcing teaching about lead poisoning to the parents. Which statements made by a parent indicate that teaching has been successful? Select all that apply.
- A. I should have our home inspected for the source of lead.
- B. I will vacuum our hard-surface floors daily.
- C. I will wash my child's hands often, especially before eating.
- D. We should use hot water from the tap for cooking.
- E. We will have to return for a follow-up lead level.
Correct Answer: A,C,E
Rationale: Inspecting the home identifies lead sources (e.g., paint, dust). Frequent hand washing reduces ingestion of lead dust. Follow-up testing monitors levels. Vacuuming may spread lead dust; wet mopping is preferred. Hot water can leach lead from pipes; cold water is safer.
The nurse is caring for a client who has no pulse and is experiencing the cardiac rhythm in the ECG strip shown below. The client has a do not attempt resuscitation directive. The health care provider (HCP) orders initiation of resuscitative measures. Which of the following actions should the nurse take?
- A. Initiate chest compressions.
- B. Clarify the order with the HCP.
- C. Prepare the client for defibrillation.
- D. Verify the client's wishes with the family.
Correct Answer: B
Rationale: A client with a Do Not Attempt Resuscitation (DNAR) or Do Not Resuscitate (DNR) directive has legally chosen not to receive resuscitative measures, such as CPR or defibrillation, in the event of cardiac arrest. The nurse has an ethical and legal obligation to honor the client's advanced directive.
The nurse is reinforcing teaching about how to use a metered-dose inhaler to a 9-year-old with asthma. Place the nurse's instructions in the appropriate order. All options must be used.
- A. Exhale completely
- B. Deliver one puff of medication into spacer
- C. Place lips tightly around the mouth piece
- D. Rinse mouth with water
- E. Shake the inhaler and attach it to spacer
- F. Take a slow deep breath, and hold it for 10 seconds
Correct Answer: E,A,B,C,F,D
Rationale: The correct order is: 1) Shake the inhaler and attach it to spacer (prepares medication); 2) Exhale completely (clears lungs); 3) Deliver one puff into spacer (releases medication); 4) Place lips tightly around the mouthpiece (ensures delivery); 5) Take a slow deep breath, and hold it for 10 seconds (allows medication absorption); 6) Rinse mouth with water (prevents oral thrush).
The licensed practical nurse is monitoring a client receiving an IV of Nipride in D5W. The IV bag has a foil covering, and the nurse notes that the IV fluid has a light brownish tint. The nurse should:
- A. Discard the solution.
- B. Obtain a bag of normal saline.
- C. Cover both the solution bag and the IV tubing with foil.
- D. Do nothing because the solution is expected to be light brown in color.
Correct Answer: D
Rationale: Nipride (nitroprusside) is light-sensitive and turns light brown, which is normal if protected by foil. No action is needed.