Nokea
The nurse monitoring a newborn after birth observes a bluish discoloration of the hands and feet. The trunk is pink. What is the nurse's initial action?
- A. Apply blow-by oxygen and count respirations
- B. Auscultate heart tones for a murmur
- C. Observe for expiratory grunting
- D. Place infant skin-to-skin with mother
Correct Answer: D
Rationale: Acrocyanosis is normal in newborns. Skin-to-skin contact promotes thermoregulation and bonding.
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The nurse at an orthopedic joint clinic is assisting with the preparation of pre-operative teaching for clients scheduled for total hip replacement surgery. Which would be included in the teaching plan?
- A. Avoid sitting in a recliner
- B. Make sure that commode seats are at low levels
- C. Avoid crossing the legs when sitting
- D. Physical therapy will assist with adduction leg exercises
Correct Answer: C
Rationale: The client with joint hip replacement should avoid adduction of the legs and flexion of the hips greater than 90 degrees to ensure continued placement of the prosthetic joint. It is recommended for these clients to use recliners for seating instead of straight chairs, therefore A is incorrect. Commode seats will have to be raised and abduction of the legs is required, making B and D incorrect choices.
The nurse is caring for a client with major depressive disorder. Which of the following findings would be consistent with the condition?
- A. hypervigilance and intrusive memories
- B. impulsivity and intense fear of abandonment
- C. changes in appetite and personal hygiene
- D. extreme shyness and hypersensitivity to criticism
Correct Answer: C
Rationale: Major depressive disorder is characterized by symptoms such as changes in appetite, sleep disturbances, and neglect of personal hygiene due to low energy and motivation.
A client with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia has been receiving IV vancomycin for the last 3 days. Which blood test trend is most important for the nurse to review when preparing to administer this medication?
- A. Blood cultures
- B. Creatinine levels
- C. Magnesium levels
- D. White blood cell (WBC) count
Correct Answer: B
Rationale: Vancomycin can cause nephrotoxicity, so monitoring creatinine levels is critical to assess kidney function.
The doctor has ordered 1 mg of Stadol (butorphanol) to be given IM. The medication is available in 4 mg per mL. The nurse should administer:
- A. 0.5 mL
- B. 0.25 mL
- C. 0.75 mL
- D. 1.0 mL
Correct Answer: B
Rationale: Calculate: 1 mg ÷ 4 mg/mL = 0.25 mL. This ensures the correct dose of Stadol is administered.
An adult woman has been diagnosed with varicose veins. Which aspect of her history is most likely related to her diagnosis?
- A. She has had five term pregnancies.
- B. She runs several marathons a year.
- C. She is 5 feet, 6 inches tall and weighs 120 pounds.
- D. She works entering data into a computer.
Correct Answer: A
Rationale: Multiple pregnancies increase intra-abdominal pressure and venous stasis, contributing to varicose veins. Running, normal weight, and sedentary work are less directly related.