Nokea
The nurse would monitor the client for which of the following?
- A. Trousseau's sign
- B. Hypoglycemia
- C. Hypokalamia
- D. Respiratory changes
Correct Answer: A
Rationale: Trousseau's sign is a clinical sign characterized by carpal spasm induced by inflating a blood pressure cuff above the systolic pressure for a few minutes. It is indicative of hypocalcemia, specifically low calcium levels in the blood. Therefore, the nurse would monitor the client for Trousseau's sign to assess for potential hypocalcemia. This could prompt the healthcare provider to order further diagnostic tests or interventions to address the underlying calcium imbalance. Options B, C, and D do not directly relate to monitoring for Trousseau's sign.
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The nurse is assessing a 3-day-old, breastfed newborn who weighed 7 pounds, 8 ounces at birth. The newborn's mother is now concerned that the newborn weighs 6 pounds, 15 ounces. Which is the most appropriate nursing intervention?
- A. Recommend supplemental feedings of formula.
- B. Explain that this weight loss is within normal limits.
- C. Assess child further to determine cause of excessive weight loss.
- D. Encourage mother to express breast milk for bottle feeding the newborn.
Correct Answer: B
Rationale: It is normal for newborns to lose weight in the first few days of life, typically up to 10% of their birth weight. In this case, the newborn's weight loss from 7 pounds, 8 ounces to 6 pounds, 15 ounces is within the expected range. It is important for the nurse to reassure the mother that this weight loss is normal and to encourage continued breastfeeding on demand to support newborn hydration and nutrition. There is no need for supplemental feedings at this point unless there are other signs of feeding issues or concerns.
Hemangiomas are the most common benign tumors of infancy, occurring more in full-term infants. Of the following, the most common risk factor of development of hemangioma is
- A. male infant
- B. female infant
- C. infant of diabetic mother
- D. infant delivered by cesarean section
Correct Answer: B
Rationale: Female infants are at higher risk for developing hemangiomas.
The nurse needs to administer an IM injection of 2.4 million units of penicillin G. it is supplied in a vial of 5,000,000 units of powder for injection. Instructions state to dilute with 8 mL of sterile water. How manu mL should the nurse draw up?
- A. 2.6 mL
- B. 4.1 mL
- C. 3.8 mL
- D. 4.4 mL
Correct Answer: B
Rationale: To administer an IM injection of 2.4 million units of penicillin G, the nurse should first reconstitute the penicillin powder with sterile water as per the instructions. The vial contains 5,000,000 units of the powder and when diluted with 8 mL of sterile water, the resulting concentration would be:
A male client who is HIV positive is admitted to the hospital with a diagnosis of Pneumocystis carinii pneumonia. His live-in partner has accompanied him. During the history interview, the nurse is aware of feeling a negative attitude about the client's lifestyle, what action is most appropriate?
- A. Share these feelings with the client
- B. Discuss the negative feelings with the
- C. Develop a written interview form charge nurse
- D. Avoid eye contact with the client
Correct Answer: B
Rationale: It is important for the nurse to acknowledge and address any negative feelings or biases that may arise during patient care, especially when caring for a patient with a stigmatized condition like HIV/AIDS. Discussing these negative feelings with a trusted colleague, such as the charge nurse, can help the nurse process and overcome their biases in a safe and non-judgmental environment. By addressing these feelings, the nurse can ensure that they provide compassionate and professional care to the patient and their partner without any personal biases interfering with the care delivery. Sharing these feelings with the client or avoiding eye contact would be inappropriate and counterproductive to establishing trust and providing care. Developing a written interview form would not address the underlying issue of negative attitudes or biases and may not be effective in promoting unbiased care.
Seven girls were victims of food poisoning after eating the sandwiches served at snack time. Which of the following statement are true regarding food poisoning?
- A. Symptoms include salivation, cramping, nausea, vomiting and diarrhea
- B. Foods that are handled and allowed to remain without refrigeration before eaten are most dangerous
- C. Cooking will destroy the organism and stop production of enterotoxin
- D. All are correct
Correct Answer: D
Rationale: A. Symptoms of food poisoning can indeed include salivation (due to excess saliva production), cramping, nausea, vomiting, and diarrhea. These symptoms are common manifestations of foodborne illnesses caused by harmful bacteria or toxins present in contaminated food.