Nokea
The parent of a 7-month-old reports that the child has been crying and vomiting with a distended belly for the past 4 hours. The infant is now lying quietly in the parent's arms with a pulse of 200/min and respirations of 60/min. Which of the following components of SBAR (situation, background, assessment, recommendation/read back) communication is most important for the nurse to report?
- A. Client has been ill for approximately 4 hours
- B. Client has improved from apparent earlier distress
- C. Client is now lethargic with abnormal vital signs
- D. Does the health care provider want to order a laxative?
Correct Answer: C
Rationale: The infant's lethargy with tachycardia (200/min) and tachypnea (60/min) are critical, suggesting a serious condition like intussusception or volvulus, requiring urgent reporting. Duration , perceived improvement , and laxative suggestion are less critical.
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The nurse is caring for 2 children who have had surgical repair of congenital heart defects. For which defect is it a priority to assess for findings of heart conduction disturbance?
- A. Arterial septal defect
- B. Patent ductus arteriosus
- C. Aortic stenosis
- D. Ventricular septal defect
Correct Answer: D
Rationale: Ventricular septal defect. Surgical repair involves manipulation of the ventricular septum, increasing the risk of conduction disturbances.
Laboratory Reference Ranges
Glucose – Fasting
70–110 mg/dL
(3.9–6.1 mmol/L)
A client with type 1 diabetes is prescribed NPH insulin before breakfast and dinner. Although the client reports feeling well, the 6 AM fasting blood glucose is 60 mg/dL. Which action should the nurse recommend to the client?
- A. Collect urine sample to check for urine ketones
- B. Consume a snack of milk and cereal at bedtime
- C. Increase carbohydrate intake at each meal
- D. Take only the prebreakfast dose of NPH
Correct Answer: B
Rationale: A fasting blood glucose of 60 mg/dL indicates hypoglycemia risk with NPH insulin, which peaks overnight. A bedtime snack prevents nocturnal hypoglycemia. Ketones are checked for hyperglycemia, increased carbohydrates may cause hyperglycemia, and skipping doses disrupts control.
The nursing care plan for a client with decreased adrenal function should include
- A. Encouraging activity
- B. Placing client in reverse isolation
- C. Limiting visitors
- D. Measures to prevent constipation
Correct Answer: C
Rationale: Limiting visitors. Limiting visitors reduces physical and emotional exertion, preventing an Addisonian crisis.
The physician has ordered a sterile urine specimen to be collected from a client who has a Foley catheter. To obtain a sterile urine specimen, the nurse should:
- A. Use a luer lock syringe and withdraw from the bulb port.
- B. Disconnect the catheter from the drainage bag.
- C. Open the urine bag and remove the specimen.
- D. Use a syringe and withdraw from the catheter port.
Correct Answer: D
Rationale: Withdrawing from the catheter port with a syringe ensures a sterile specimen. Other methods risk contamination.
The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing?
- A. Apply dressing using sterile technique
- B. Improve the client's nutrition status
- C. Initiate limb elevation and compression
- D. Begin proteolytic debridement
Correct Answer: B
Rationale: The goal of clinical management in a client with venous stasis ulcers is to promote healing. This only can be accomplished with proper nutrition. The other interventions are appropriate, but without proper nutrition, they would be of little help.