Nokea
The nurse is preparing to administer an injection to a 6-month-old when she notices a white dot in the infant's right pupil. The nurse should:
- A. Report the finding to the physician immediately
- B. Record the finding and give the infant's injection
- C. Recognize that the finding is a variation of normal
- D. Check both eyes for the presence of the red reflex
Correct Answer: A
Rationale: A white dot in the pupil (leukocoria) may indicate retinoblastoma or cataracts, requiring immediate reporting to the physician for further evaluation.
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The doctor has ordered a Transcutaneous Electrical Nerve Stimulation (TENS) unit for the client with chronic back pain. The nurse teaching the client with a TENS unit should tell the client:
- A. You may be electrocuted if you use water with this unit.'
- B. Please report skin irritation to the doctor.'
- C. The unit may be used anywhere on the body without fear of adverse reactions.'
- D. A cream should be applied to the skin before applying the unit.'
Correct Answer: B
Rationale: Skin irritation is a common side effect of TENS; reporting it ensures timely management.
The nurse is caring for a client who is 12 weeks pregnant and presented with the following symptoms: mild uterine cramping with spotting of blood. The cervical os is closed upon examination. How should the nurse chart the findings?
- A. missed miscarriage
- B. complete miscarriage
- C. inevitable miscarriage
- D. threatened miscarriage
Correct Answer: D
Rationale: Mild cramping, spotting, and a closed cervical os at 12 weeks indicate a threatened miscarriage, where the pregnancy may still continue.
The nurse is aware that African-Americans are at higher risk than Caucasians for which of the following conditions? Select all that apply.
- A. Hypertension.
- B. Diabetes mellitus.
- C. Asthma.
- D. Skin cancer.
- E. Osteoporosis.
Correct Answer: A,B
Rationale: African-Americans have a higher risk for hypertension (A) and diabetes mellitus (B) compared to Caucasians due to genetic and socioeconomic factors. Asthma (C) risk is similar across groups, while skin cancer (D) and osteoporosis (E) are less prevalent in African-Americans.
A patient is rushed to the emergency room after being found unconscious at home. His blood pressure is 70/35. The nurse anticipates an order for what medication?
- A. atropine sulfate (Atropine)
- B. amiodarone (Cordarone)
- C. magnesium sulfate
- D. adenosine (Adenoscan)
- E. None
- F. All the above
Correct Answer: E
Rationale: For severe hypotension (BP 70/35), vasopressors like norepinephrine or dopamine are typically ordered to restore perfusion, but none of the listed options are vasopressors. The question may be flawed.
The nurse is caring for a client admitted to ICU following a heart attack. The nurse notes on the chart that the client has named his spouse to make decisions regarding his care if he is unable to speak for himself. What is the name of the document the client has signed? Fill in the blank.
- A. Living Will
- B. Do Not Resuscitate Order
- C. Durable Power of Attorney for Healthcare
- D. Advance Directive
Correct Answer: C
Rationale: The document is a **Durable Power of Attorney for Healthcare** or **Healthcare Proxy**, designating the spouse as the decision-maker.