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The nurse is feeding a 3-month-old client with tetralogy of Fallot. During the feeding, the client becomes cyanotic and has difficulty breathing. Which action should the nurse take first?
- A. Administer oxygen via face mask to the client
- B. Administer subcutaneous morphine to the client
- C. Obtain the client's pulse oximetry reading
- D. Place the client in the knee-chest position
Correct Answer: D
Rationale: The knee-chest position increases systemic vascular resistance and reduces right-to-left shunting in tetralogy of Fallot, immediately improving oxygenation during a tet spell.
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The nurse in a long-term care facility observes a nursing assistant caring for a resident who has a hearing aid and dentures. Which action by the nursing assistant should be corrected?
- A. The nursing assistant places a washcloth in the sink before brushing the client's dentures.
- B. The nursing assistant uses toothpaste to clean the dentures.
- C. The nursing assistant uses alcohol to wipe off the exterior of the hearing aid.
- D. The nursing assistant wipes the exterior of the hearing aid with a damp cloth.
Correct Answer: C
Rationale: The exterior of a hearing aid should be wiped regularly with a damp cloth. Alcohol should not be used as it can damage the device. The nursing assistant should place a washcloth in the sink before brushing dentures to protect them if dropped. Toothpaste is appropriate to clean dentures.
Which of the following conditions is most likely related to the development of renal calculi?
- A. Gout
- B. Pancreatitis
- C. Fractured femur
- D. Disc disease
Correct Answer: A
Rationale: Gout increases uric acid levels, which can lead to uric acid kidney stones, a common type of renal calculi.
The nurse is screening clients for those at risk for developing a pressure injury. At highest risk for developing a pressure injury is the client
- A. who had an open cholecystectomy and has a closed-wound drainage device
- B. who has a long leg cast and a decreased serum albumin level
- C. with dementia, peripheral artery disease, and constipation
- D. with quadriplegia, moist skin, and an elevated temperature
Correct Answer: D
Rationale: Clients with quadriplegia are at high risk due to immobility, which impairs circulation and increases pressure on skin. Moist skin increases the risk of skin breakdown, and elevated temperature may indicate infection or inflammation, further increasing risk.
A 6-year old is admitted with a diagnosis of childhood autism. Which behavior is most typical of the child with autism?
- A. A willingness to talk to strangers
- B. A disinterest in inanimate objects
- C. Engaging in ritualistic behavior
- D. A dislike of music
Correct Answer: C
Rationale: Children with autism often engage in ritualistic or repetitive behaviors, such as specific routines or movements, as a hallmark of the condition. Choice A is incorrect because children with autism typically have social communication difficulties and are less likely to engage with strangers. Choice B is incorrect as they may show intense interest in specific inanimate objects. Choice D is incorrect as music preference varies and is not a defining characteristic.
The nurse is assisting with the care of four clients with diabetes mellitus. Which of the following prescriptions should the nurse clarify with the health care provider?
- A. 10 units regular insulin IV push for serum glucose level >250 mg/dL (13.9 mmol/L)
- B. 14 units glargine insulin subcutaneous injection every night at 2000
- C. 18 units aspart insulin subcutaneous injection 15 minutes before breakfast
- D. 20 units NPH insulin IV push administered every morning at 700
Correct Answer: D
Rationale: NPH insulin is not administered IV, as it is a suspension and can cause embolism or erratic absorption. This prescription requires clarification.