Nokea
A 4 lb 10 oz baby boy delivered at 32 weeks gestation. The infant is admitted to the neonatal intensive care unit and placed in an incubator. He has mottling of the skin and acrocyanosis with irregular respirations of 60.
The nurse should recognize these findings as signs of
- A. hypoglycemia.
- B. cold stress.
- C. birth asphyxia.
- D. hypovolemia.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) blood sugar less than 25 mg/dL, would see cyanosis, apnea, tachypnea, irregular respirations, diaphoresis, jitteriness, weak cry, lethargy, convulsions, coma (2) correct-symptoms describe cold stress (3) would see meconium stained amniotic fluid (4) would see symptoms of shock
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The nurse is caring for clients(width)clients in the pediatric clinic.
- A. Which cranial nerve should the nurse assess in an infant with a 'crooked' smile?
- B. III.
- C. V.
- D. VII.
- E. XI.
Correct Answer: C
Rationale: A crooked smile in an infant suggests facial muscle weakness, controlled by the facial nerve (VII), which governs facial expressions. Cranial nerves III (eye movement), V (sensation), and XI (neck/shoulder movement) are unrelated to smiling.
The nurse is caring for an older adult. Which statement made by the client is not typical of normal aging?
- A. I seem to be more sensitive to the taste of salt than I used to be.'
- B. I have trouble reading the newspaper.'
- C. I don't drive at dusk anymore.'
- D. Sometimes I have trouble matching my socks.'
Correct Answer: A
Rationale: Increased sensitivity to salt taste is not typical of aging; taste sensitivity usually decreases. Difficulty reading, avoiding dusk driving, and color matching issues are normal aging changes.
The nurse is caring for a client with a chest tube. On the second postoperative day, the chest tube accidentally disconnects from the drainage tube. The first action the nurse should take is
- A. reconnect the tube
- B. raise the collection chamber above the client's chest
- C. call the health care provider
- D. clamp the chest tube
Correct Answer: D
Rationale: Immediate steps should be taken to prevent air from entering the chest cavity. Lung collapse may occur if air enters the chest cavity. Clamping the tube close to the client's chest is the first action to take, followed by health care provider notification.
Which of these clients would the nurse monitor for the complication of C. difficile diarrhea?
- A. An adolescent taking medications for acne
- B. An elderly client living in a retirement center taking prednisone
- C. A young adult in the second trimester of pregnancy
- D. A middle-aged client receiving radiation for throat cancer
Correct Answer: D
Rationale: A middle-aged client receiving radiation for throat cancer. Radiation therapy, particularly to the abdomen or pelvis, can disrupt the gut microbiota and increase the risk of C. difficile infection, especially if the client is also receiving antibiotics or has a weakened immune system.
The nurse is performing a sterile dressing change. Which action is essential?
- A. Touching the corners of the dressing with clean gloves
- B. Discussing the wound with the client during the dressing change
- C. Irrigating the wound with an antiseptic solution
- D. Wearing sterile gloves during the dressing change
Correct Answer: D
Rationale: Wearing sterile gloves maintains a sterile field, essential for preventing infection during a sterile dressing change.