Nokea
The nurse observes a parent swaddling their infant with an unrepaired omphalocele. Which of the following statements would be appropriate?
- A. Stop! You will kill your baby.
- B. That is a nice, tight swaddle. It will help soothe your new baby.
- C. May I help you? We must be careful with the baby's intestines since we do not want the swaddle to push them back inside.
- D. Swaddling is not allowed for these babies; please stop.
Correct Answer: C
Rationale: This statement educates the parent gently, explaining the risk to the omphalocele without alarming them.
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The nurse is caring for a 2-hour-old infant at risk for cold stress. Which of the following assessment findings would support an early finding of cold stress?
- A. shivering
- B. hyperglycemia
- C. tachycardia
- D. bradypnea
Correct Answer: C
Rationale: Tachycardia is an early sign of cold stress as the infant attempts to increase metabolism to maintain body temperature.
The nurse is discharging an adolescent with sickle cell disease. Which statement should the nurse include in the teaching?
- A. Keep a water bottle with you at school so that you can stay hydrated
- B. Follow a high-calorie, high-protein diet
- C. Do not take the annual influenza vaccine
- D. Drink extra fluids if you have to travel on an airplane
- E. Daily aerobic exercise is recommended
Correct Answer: A, B, D
Rationale: Hydration, high-calorie/protein diet, and extra fluids during travel help prevent sickle cell crises. The influenza vaccine is recommended, and excessive aerobic exercise may trigger crises.
The nurse reviews a client's medical record taking prescribed isoniazid for pulmonary tuberculosis. Which laboratory data is most important to monitor?
- A. PT and PTT
- B. CBC
- C. BUN
- D. Liver enzymes
Correct Answer: D
Rationale: Isoniazid can cause hepatotoxicity, making liver enzyme monitoring critical.
The nurse receives a prescription to administer dopamine at 5 mcg/kg/min. The nurse has a bag labeled with dopamine 200 mg in 250 mL of D5W on hand. The client weighs 81.81 kg (179.98 lbs). How many mL/hr will the nurse administer?
Correct Answer: 31 mL/hr
Rationale: Calculation: 81.81 kg x 5 mcg/kg/min = 409.05 mcg/min x 60 = 24,543 mcg/hr = 24.543 mg/hr. Dopamine: 200 mg/250 mL = 0.8 mg/mL. 24.543 / 0.8 = 30.68 mL/hr, rounded to 31 mL/hr.
The nurse in the outpatient clinic is caring for a 33-year-old female.
Item 1 of 1
Nurses' Note
1435: Client reports vaginal discharge that is malodorous x 3 days. The client reports that the discharge is thin, green, and yellow. She reports being sexually active with multiple partners without any protection. She denies any dysuria, dyspareunia, fevers, chills, or fatigue. The client is alert and oriented to person, place, and time. Reports no pain. Lung sounds are clear, with a regular breathing pattern. Active bowel sounds in all quadrants. Peripheral pulses were 2+ and regular—no peripheral edema. Skin is warm and moist. Vital signs: T 98° F (36.7° C), P 72, RR 18, BP 132/76, pulse oximetry reading 98% on room air.
Complete the following sentences by choosing from the lists of options. The client is demonstrating signs and symptoms of ___ To confirm this diagnosis, the nurse anticipates a physician's order for...........
- A. syphilis
- B. trichomoniasis
- C. urolithiasis
- D. human immunodeficiency virus (HIV)
- E. wet mount microscopy
- F. RPR (rapid plasma reagin)
- G. HIV p24 antigen
Correct Answer: B, E
Rationale: The client's symptoms of malodorous, thin, green, and yellow vaginal discharge are characteristic of trichomoniasis, a sexually transmitted infection caused by Trichomonas vaginalis. Wet mount microscopy is the appropriate diagnostic test to confirm this by identifying the parasite.