Nokea
The nurse is reviewing the chart of a 1-day-old infant. Which of the following data requires further action?
- A. Heart rate of 128
- B. Respiratory rate of 72
- C. Hematocrit of 50%
- D. Blood glucose of 60 mg/100 mL
Correct Answer: B
Rationale: A respiratory rate of 72 is elevated for a newborn (normal 30-60 breaths/min), suggesting potential respiratory distress requiring further evaluation.
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The nurse enters the room as a 3 year-old is having a generalized seizure. Which intervention should the nurse perform first?
- A. Clear the area of any hazards
- B. Place the child on its side
- C. Restrain the child
- D. Give the prescribed anticonvulsant
Correct Answer: B
Rationale: Place the child on its side. Protecting the airway is the top priority in a seizure to ensure a patent airway and oxygenation.
The nurse is caring for a client with a history of heart failure who is receiving furosemide (Lasix) 40 mg PO daily. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Potassium 3.2 mEq/L.
- B. Sodium 138 mEq/L.
- C. Creatinine 1.0 mg/dL.
- D. Glucose 100 mg/dL.
Correct Answer: A
Rationale: Furosemide, a loop diuretic, can cause hypokalemia, and a potassium level of 3.2 mEq/L is low, increasing the risk of arrhythmias in heart failure. Options B, C, and D are normal: sodium 138 mEq/L, creatinine 1.0 mg/dL, and glucose 100 mg/dL do not require immediate action.
The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who is receiving ipratropium (Atrovent) via inhaler. Which of the following client statements would be of GREATest concern to the nurse?
- A. I use my inhaler four times a day.
- B. I have a dry mouth.
- C. I feel dizzy sometimes.
- D. I rinse my mouth after using the inhaler.
Correct Answer: C
Rationale: Dizziness may indicate systemic absorption or hypoxia, a serious concern in COPD requiring evaluation. Options A, B, and D are less concerning: four times daily is standard, dry mouth is a common side effect, and rinsing is appropriate.
An adult is hospitalized for heart failure. Hydrochlorothiazide and digoxin are prescribed. What laboratory test(s) should the nurse monitor because the client is taking these medications?
- A. CBC and differential
- B. Serum creatinine and BUN
- C. Cardiac enzymes
- D. Serum electrolytes
Correct Answer: D
Rationale: Hydrochlorothiazide and digoxin can cause electrolyte imbalances (e.g., hypokalemia), increasing digoxin toxicity risk, necessitating serum electrolyte monitoring.
The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who is receiving salmeterol (Serevent) via inhaler. Which of the following client statements would be of GREATest concern to the nurse?
- A. I use my inhaler twice a day.
- B. I have a dry mouth.
- C. I feel shaky sometimes.
- D. I rinse my mouth after using the inhaler.
Correct Answer: C
Rationale: Shakiness suggests systemic beta-agonist effects, a concerning side effect of salmeterol in COPD, requiring evaluation to prevent tachycardia or arrhythmias. Options A, B, and D are less concerning: twice-daily use is standard, dry mouth is common, and rinsing is appropriate.