The nurse is preparing discharge teaching for the parents of a newborn. Which of the following information should the nurse provide to the parents regarding the accuracy of a PKU (phenylketonuria) Test ?
- A. Breast-fed babies need to be a week old for the Test , and infants on formula can be Test ed in three days.
- B. The Test will need to be repeated at six weeks and at the three-month.pnlcheck-up.
- C. Blood will be drawn at three one-hour intervals; there is no specific preparation.
Correct Answer: A
Rationale: formula or cow's milk contains high phenylalanine levels; Test can be done after three days of formula intake; if mother is breastfeeding, infant will need to return in one week for Test
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A Hispanic client refuses emergency room treatment until a curandero is called. The nurse understands that this person brings what to situations of illness?
- A. Holistic healing
- B. Spiritual advising
- C. Herbal preparations
- D. Witchcraft potions
Correct Answer: A
Rationale: Holistic healing. This traditional folk practitioner uses holistic methods for illnesses, often working with traditional health care providers.
Which laboratory result would be expected during the emergent phase of a burn injury?
- A. Glucose 100 mg/dl
- B. Potassium 3.5 mEq/l
- C. Sodium 142 mEq/l
- D. Albumin 4.2 gm/dl
Correct Answer: A
Rationale: Glucose levels rise as a result of the stress response during the emergent phase. Answers B, C, and D are within normal range. K+ and Na+ would be elevated, whereas albumin would be lowered during the emergent period due to increased permeability.
The nursing team consists of one RN, two LPNs/LVNs, and three nursing assistants. The RN should care for which of the following patients?
- A. A patient with a chest tube who is ambulating in the hall.
- B. A patient with a colostomy who requires assistance with an irrigation.
- C. A patient with a right-sided cerebral vascular accident (CVA) who requires assistance with bathing.
- D. A patient who is refusing medication to treat cancer of the colon.
Correct Answer: D
Rationale: requires assessment skills of the RN
The nurse is observing a certified nursing assistant (CNA) caring for a client who has AIDS. Which action, if observed, is not correct?
- A. The CNA wears gloves when cleaning the client after an episode of fecal incontinence.
- B. The CNA uses chlorine bleach to wipe up blood after the client cut himself shaving.
- C. The CNA is observed giving the client a back rub without gloves on.
- D. The CNA wears a mask whenever entering the client's room.
Correct Answer: C
Rationale: Standard precautions require gloves during contact with non-intact skin or bodily fluids, including during a back rub for an AIDS client, to prevent transmission. Gloves for incontinence, bleach for blood, and masks (if indicated) are appropriate.
The nurse is caring for a client with asthma who has developed gastroesophageal reflux disease (GERD). Which of the following medications prescribed for the client may aggravate GERD?
- A. Anticholinergics
- B. Corticosteroids
- C. Histamine blocker
- D. Antibiotics
Correct Answer: A
Rationale: An anticholinergic medication will decrease gastric emptying and the pressure on the lower esophageal sphincter.
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