The nurse is monitoring a newborn with skin discoloration in the buttock and lumbar area. Which action by the nurse is appropriate?
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- A. Check the newborn's hemoglobin, hematocrit, and platelet levels
- B. Measure and document the size and location of the markings
- C. Notify the registered nurse of the markings immediately
- D. Review the delivery record for evidence of a traumatic birth
Correct Answer: B
Rationale: Skin discoloration in the buttock and lumbar area of a newborn is often due to Mongolian spots (also called congenital dermal melanocytosis). These are benign, flat, bluish-gray patches typically found on the lower back or buttocks. They are more common in infants with darker skin tones and are not harmful, but they can be mistaken for bruises, which raises concern for abuse later on.
The appropriate nursing action is to measure and document the size, shape, and location of the spots in the medical record. This ensures that there is a clear, dated record of the findings to avoid confusion in the future.
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A client with AIDS treated for intractable seizures is transferred from the intensive care unit to the medical unit. There are 4 semiprivate room beds available. Which room assignment does the nurse recognize as the best option for this client?
- A. Client with Clostridium difficile
- B. Client with community-acquired pneumonia
- C. Client with fever of unknown origin
- D. Client with upper gastrointestinal bleed
Correct Answer: B
Rationale: Community-acquired pneumonia poses the least infection risk to an immunocompromised client with AIDS, unlike C. difficile or fever of unknown origin.
A 64-year-old client is prescribed ciprofloxacin for a urinary tract infection. The nurse reminds the client to observe for and notify the health care provider immediately about which of the following?
- A. Brown-colored urine
- B. Hearing and balance problems
- C. Pain in the Achilles tendon area
- D. Sunburn
Correct Answer: C
Rationale: Ciprofloxacin is associated with Achilles tendon rupture, a serious side effect requiring immediate reporting. Other symptoms are less specific.
The nurse is providing diet instruction to the parents of a child with cystic fibrosis. The nurse would emphasize that the diet should be
- A. High calorie, low fat, low sodium
- B. High protein, low fat, low carbohydrate
- C. High protein, high calorie, unrestricted fat
- D. High carbohydrate, low protein, moderate fat
Correct Answer: C
Rationale: High protein, high calorie, unrestricted fat. The child with Cystic Fibrosis needs a well balanced diet that is high in protein and calories. Fat does not need to be restricted.
A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client's temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is
- A. Maintain fluid and electrolyte balance
- B. Control nausea
- C. Manage pain
- D. Prevent urinary tract infection
Correct Answer: C
Rationale: Manage pain. The immediate goal of therapy is to alleviate the client's pain, which can be quite severe with kidney stones.
The nurse is preparing the room of a client returning from a subtotal thyroidectomy. Which item should be placed at the bedside of a client with a subtotal thyroidectomy?
- A. An ambu bag
- B. A tracheostomy set
- C. An endotracheal tube
- D. A ventilator
Correct Answer: B
Rationale: A tracheostomy set is essential post-thyroidectomy due to the risk of airway obstruction from swelling or hematoma. Other equipment is less immediately relevant.