Nokea
The nurse is transporting a mother and her newborn upon discharge from the hospital. When the nurse is assisting the mother and newborn into the car, the nurse notes that the car is equipped with a front-facing car seat that is in the front seat of the car. Which action is most appropriate for the nurse?
- A. Position the infant in the car seat as positioned.
- B. Explain that a rear-facing car seat is necessary and offer to lend the family a car seat from the hospital for the trip home.
- C. Tell the mother that holding the infant is safer than putting the infant in a front-facing car seat.
- D. Place the car seat in the back seat and position the infant appropriately.
Correct Answer: B
Rationale: Infants require rear-facing car seats in the back seat for safety. Offering a hospital car seat ensures proper transport safety.
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The nurse’s INITIAL priority when managing a physically assaultive client is to
- A. What is the initial priority when managing a physically assaultive client?
- B. Restrict the client to the room.
- C. Place the client under one-to-one supervision.
- D. Restore the client’s self-control and prevent further loss of control.
- E. Clear the immediate area of other clients to prevent harm.
Correct Answer: C
Rationale: Restoring the client’s self-control is the initial priority to ensure safety and prevent escalation. This involves assessing the situation, using psychological or chemical interventions, and possibly physical control. Room restriction, supervision, or clearing the area are secondary or impractical during rapid escalation.
A patient with hyperparathyroidism.
Which symptom is MOST important for the nurse to report to the next shift?
- A. Abdominal discomfort.
- B. Hematuria.
- C. Muscle weakness.
- D. Diaphoresis.
Correct Answer: B
Rationale: Strategy: Determine how each answer choice relates to hyperparathyroidism. (1) sign of hyperparathyroidism but does not require reporting (2) correct-hematuria is a sign of renal calculi; 55% of hyperparathyroid clients have renal stones (3) sign of hyperparathyroidism but does not require reporting (4) sign of hyperparathyroidism but does not require reporting
The nurse is aware that which of the following assessments would be indicative of hypocalcemia?
- A. Constipation.
- B. Depressed reflexes.
- C. Decreased muscle strength.
- D. Positive Trousseau's sign.
Correct Answer: D
Rationale: positive Trousseau's sign is indicative of neuromuscular hyperreflexia associated with hypocalcemia
The nurse is teaching a client with a new diagnosis of epilepsy about valproic acid (Depakote). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice.
- B. Report any bruising or bleeding.
- C. Stop the medication if seizures decrease.
- D. Avoid regular liver function Test s.
Correct Answer: B
Rationale: Valproic acid can cause thrombocytopenia; reporting bruising or bleeding is critical. Options A, C, and D are incorrect or unsafe.
The nurse is caring for a client with a nasogastric tube.
- A. What is the most appropriate action for the nurse to take if the nasogastric tube appears occluded?
- B. Replace the nasogastric tube.
- C. Irrigate the tube with warm saline.
- D. Advance the tube 3-5 cm.
- E. Reposition the client to the left side.
Correct Answer: B
Rationale: Irrigating the nasogastric tube with warm saline is the first step to clear an occlusion, restoring function. Replacing the tube is invasive, advancing it risks misplacement, and repositioning does not address the occlusion directly.