Nokea
The nurse is unsuccessful in inserting a nasogastric tube for a newborn client. The nurse suspects the newborn has esophageal atresia/tracheoesophageal (EA/TE) fistula. Which nursing action is appropriate while waiting for the healthcare provider to further assess the neonate?
- A. Position the newborn in a semi-Fowler position.
- B. Allow the newborn to stay in the nursery for observation.
- C. Offer the newborn pacifier for comfort.
- D. Wrap the newborn in blankets and place in an incubator.
Correct Answer: A
Rationale: Positioning the newborn in a semi-Fowler position is appropriate as it helps prevent aspiration in suspected EA/TE fistula. This position helps reduce the risk of regurgitation and aspiration of gastric contents. Placing the newborn in a semi-Fowler position promotes the drainage of secretions and reduces the risk of complications while awaiting further assessment by the healthcare provider.
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The closeness of a measured value to a standard or known value is termed as
- A. accuracy
- B. precision
- C. sensitivity
- D. specificity
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 9mo-old infant develops a left adrenal mass; histological examination with genetic characteristics confirms neuroblastoma. Which of the following carries a better outcome?
- A. amplification of the MYCN (N-myc) proto-oncogene
- B. hyperdiploidy
- C. loss of heterozygosity of 17q chromosome
- D. loss of 1p chromosome
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A pediatric client is admitted to the emergency department with a traumatic brain injury (TBI) that caused a loss of consciousness. The last set of vital signs showed heart rate 48, blood pressure (BP) 148/74 mmHg, respiratory rate 28 and irregular. What does the nurse suspect based on these data?
- A. Spinal cord injury
- B. Increased intracranial pressure
- C. Typical for sleep
- D. Improvement
Correct Answer: B
Rationale: The vital signs of bradycardia, hypertension, and irregular respirations indicate increased intracranial pressure. Bradycardia (heart rate of 48), hypertension (blood pressure of 148/74 mmHg), and irregular respirations are typical signs of increased intracranial pressure in a pediatric client with a traumatic brain injury and loss of consciousness.
A 9-year-old girl builds a clubhouse in her backyard and hangs a sign reading 'No boys allowed.' What should the school nurse tell the parents?
- A. Her behavior is concerning and should be addressed.
- B. Her behavior is common among school-age children.
- C. Her feelings about boys will subside within a year.
- D. They should have her speak with a school counselor.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Before administering a live virus vaccine to a patient taking a glucocorticoid medication, what action should the nurse take?
- A. Continue screening and administer the vaccine if appropriate
- B. Note the contraindication but administer the vaccine regardless
- C. Note the contraindication and clarify the order with the healthcare provider
- D. Withhold the vaccine and inform the department of health
Correct Answer: C
Rationale: The correct action for the nurse to take when a patient on glucocorticoid medication is to note the contraindication and clarify the order with the healthcare provider. Glucocorticoids can suppress the immune response, potentially reducing the effectiveness of vaccines. Therefore, it is crucial to consult with the healthcare provider to assess the risks and benefits of administering a live virus vaccine in such circumstances. Administering a live virus vaccine to a patient taking glucocorticoids can increase the risk of developing a viral infection, making it essential to seek guidance from the healthcare provider before proceeding.