Nokea
The neonatal nurse is instructing the family of a newborn about an apnea monitor.
The nurse should be MOST concerned if a family member makes which of the following statements?
- A. We will be able to leave our baby for brief periods of time.'
- B. We plan to sleep by our baby's crib.'
- C. We can remove the monitor during our baby's bath.'
- D. A family member will closely watch the monitor all the time.'
Correct Answer: D
Rationale: Strategy: 'MOST concerned' indicates that you are looking for an incorrect statement. (1) appropriate behavior (2) appropriate behavior (3) appropriate behavior (4) correct-indicates a feeling that monitor may not let them know if their infant stops breathing
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The nurse is preparing a client for a herniorrhaphy. It would be MOST important for the nurse to complete which of the following one hour prior to surgery?
- A. Administer an enema.
- B. Confirm that the consent form has been signed.
- C. Perform a preoperative shave and scrub.
- D. Evaluate for food or medication allergies.
Correct Answer: B
Rationale: surgical consent should be rechecked prior to going to surgery
After receiving report, which of the following patients should the nurse see FIRST?
- A. A patient in sickle-cell crisis with an infiltrated IV.
- B. A patient with leukemia who has received one-half unit of packed cells.
- C. A patient scheduled for a bronchoscopy.
- D. A patient complaining of a leaky colostomy bag.
Correct Answer: A
Rationale: IV fluids are critical to reduce clotting and pain
The nurse is caring for a client with a new colostomy. Which of the following client statements indicates a need for further teaching?
- A. I will change the pouch when it is about one-third full.
- B. I will empty the pouch every evening before bed.
- C. I will avoid gas-forming foods like beans and broccoli.
- D. I will check the skin around the stoma for irritation.
Correct Answer: B
Rationale: the pouch should be emptied when one-third to one-half full, not on a fixed schedule
The nurse is caring for a client with a nasogastric (NG) tube. Which of the following actions should the nurse take to ensure proper functioning of the NG tube?
- A. Irrigate the tube with 50 mL of sterile water every 4 hours.
- B. Check for residual volume every 8 hours.
- C. Secure the tube to the client's gown only.
- D. Keep the head of the bed flat at all times.
Correct Answer: B
Rationale: checking residual volume ensures the tube is functioning and prevents overfeeding or aspiration
A three-month-old patient is experiencing increased intracranial pressure (ICP). Which of the following assessment findings should the nurse report to the physician?
- A. Pinpoint pupils.
- B. High-pitched cry.
- C. Decrease in blood pressure.
- D. Absence of reflexes.
Correct Answer: B
Rationale: sign of increased intracranial pressure