Nokea
Laboratory reference ranges
Glucose (random) – newborn < 24 hours old
40-60 mg/dL
(2.2-3.3 mmol/L)
The nurse is monitoring a neonate 1 hour after spontaneous vaginal delivery. Which of the following are expected findings? Select all that apply.
- A. respirations of 56 breaths per minute
- B. capillary glucose of 60 mg/dL (3.3 mmol/L)
- C. holosystolic murmur auscultated at fourth intercostal space
- D. single transverse crease across palm of the hand
- E. white papules on bridge of the nose
Correct Answer: A, B, E
Rationale: Respirations of 56 (A), glucose of 60 mg/dL (B), and white papules (milia) (E) are normal in neonates. A holosystolic murmur (C) and single transverse crease (D) suggest congenital abnormalities.
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The nurse is instructing the client with a fractured femur in crutch walking. When instructing the client in the best method of manipulating stairs, the nurse should tell the client to:
- A. Start up the stairs with the crutches first.
- B. Start up the stairs with the unaffected leg first.
- C. Use the affected leg to move up the stairs first.
- D. Use the unaffected leg to move down the stairs.
Correct Answer: B
Rationale: For ascending stairs, lead with the unaffected leg to bear weight, followed by crutches and affected leg. This ensures stability and safety.
A client just diagnosed with methicillin-resistant Staphylococcus aureus septic arthritis is receiving the first dose of IV vancomycin. Which finding is most concerning to the nurse?
- A. Diffuse muscle pain
- B. Flushing and pruritus
- C. Low blood pressure
- D. Wheezing and hives
Correct Answer: D
Rationale: Wheezing and hives (D) indicate a possible anaphylactic reaction, the most concerning finding. Muscle pain (A), flushing/pruritus (B), and low blood pressure (C) are less immediately life-threatening.
The nurse reinforces teaching about methotrexate to a client with rheumatoid arthritis. It is most important to address which topic regarding this drug?
- A. Need for an eye examination
- B. Need for sunblock
- C. Risk for infection
- D. Risk for kidney injury
Correct Answer: C
Rationale: Methotrexate suppresses the immune system, significantly increasing the risk for infection (C). This is a critical teaching point to ensure the client takes precautions. Eye exams (A), sunblock (B), and kidney injury (D) are less directly associated with methotrexate's primary risks.
The nurse is preparing to administer several medications through a client's feeding tube. None of the medications are extended release. Which of the following actions should the nurse implement? Select all that apply.
- A. Combine all medications and administer together
- B. Crush each medication separately before administration
- C. Determine if the medications are available in liquid form
- D. Flush the tube before and after medication administration
- E. Mix medications with enteral feeding formula before administration
Correct Answer: B, C, D
Rationale: Crushing separately (B) prevents interactions, liquid forms (C) are preferred, and flushing (D) ensures patency. Combining all medications (A) or mixing with formula (E) can cause clogs or interactions.
The nurse helps the health care provider perform a thoracentesis at the bedside. In which position does the nurse place the client to facilitate needle insertion and promote comfort?
- A. Fetal position, lying on unaffected side with knees drawn to the abdomen and hands clasped around them
- B. Lying on the affected side with head of the bed elevated to 30-45 degrees
- C. Prone with head turned to the affected side and arms over the head, supported by a pillow
- D. Upright leaning forward over the bedside table, with arms supported on pillows
Correct Answer: D
Rationale: Upright leaning forward (D) facilitates lung expansion and fluid access while ensuring comfort. Other positions (A, B, C) are less effective or uncomfortable.