Nokea
The nurse is informed that a newborn infant with Apgar scores of 1 and 4 will be brought to the nursery. The nurse determines that which intervention is the priority?
- A. Connecting the resuscitation bag to oxygen
- B. Turning on the apnea and cardiorespiratory monitor
- C. Preparing for the insertion of an intravenous (IV) line with D5W
- D. Setting up the radiant warmer control temperature at 36.5°C (97.6°F)
Correct Answer: A
Rationale: The top priority action for a newborn infant with low Apgar scores is maintaining a patent airway, which would involve preparing respiratory resuscitation equipment. Although the remaining options are also important, they are of lower priority. The newborn infant's cardiopulmonary status would be monitored by a cardiorespiratory monitoring device. Setting up an IV with D5W would provide circulatory support. The radiant warmer will provide an external heat source, which is necessary to prevent further respiratory distress.
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A client with a diagnosis of breast cancer is prescribed exemestane (Aromasin). The nurse should instruct the client to report which of the following side effects immediately?
- A. Hot flashes.
- B. Bone pain.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Bone pain may indicate bone loss or metastasis, a serious side effect of exemestane requiring immediate reporting.
A primary health care provider prescribes lipids (fat emulsion) for a client who is receiving total parenteral nutrition (TPN). The nurse should explain to the client that the fat emulsion is administered for which reason?
- A. To provide essential fatty acids
- B. As a supplement to fluid intake
- C. To decrease the risk of phlebitis
- D. Infused during the night in place of TPN
Correct Answer: A
Rationale: Lipids are a brand of intravenous fat emulsion administered to clients who are at risk for developing an essential fatty acid deficiency, such as those receiving TPN. Fat emulsions help meet caloric and nutritional needs that cannot be met by glucose administration alone. Fat emulsions are not administered to increase the amount of body fluids and they do not decrease the incidence of phlebitis. Fat emulsions neither replace TPN nor do they require infusion during the night.
The nurse is assessing a client with a suspected myocardial infarction. Which of the following findings is most indicative of this condition?
- A. Chest pain radiating to the left arm.
- B. Bilateral leg swelling.
- C. Fever.
- D. Dry cough.
Correct Answer: A
Rationale: Chest pain radiating to the left arm is a classic symptom of myocardial infarction due to cardiac ischemia.
A client is admitted to the hospital with a tentative diagnosis of urinary tract infection (UTI). The nurse should assess the client for which of the following as a precipitating factor for the UTI?
- A. High fluid intake.
- B. History of hypertension.
- C. Recent antibiotic therapy.
- D. Frequent sexual intercourse.
Correct Answer: D
Rationale: Frequent sexual intercourse is a common precipitating factor for UTIs, as it can introduce bacteria into the urinary tract.
Identify this cardiac rhythm strip. Fill in the blank. A. Torsades de Pointes B. Accelerated Idioventricular Arrhythmia C. First Degree Atrioventricular Heart Block D. Supraventricular tachycardia
- B. Torsades de Pointes
- C. Accelerated Idioventricular Arrhythmia
- D. First Degree Atrioventricular Heart Block
- E. Supraventricular tachycardia
Correct Answer: C
Rationale: First Degree AV Block is characterized by a prolonged PR interval, assuming the strip shows this pattern.