Nokea
The parent of a newborn is concerned about the possibility of the child developing hip dysplasia. Which intervention should the nurse encourage to help reduce the risk in this newborn?
- A. Choose an infant carrier with a narrow seat
- B. Place 2 diapers on the infant at all times
- C. Swaddle the infant with hips flexed and abducted
- D. Use an infant swing that keeps both legs straight
Correct Answer: C
Rationale: Swaddling with hips flexed and abducted promotes healthy hip development and reduces dysplasia risk. Narrow carriers and straight-leg swings increase risk, and double diapering is outdated and ineffective.
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A 72-year-old woman is being treated for pneumonia. Physician's orders include an antibiotic, oxygen PRN for O2 saturation less than 90, and pulse oximetry every 4 hours. The nurse obtains a pulse oximetry reading of 82% on room air. What is the best action for the nurse to take?
- A. Report the finding to the physician
- B. Report the finding to the registered nurse to get instructions
- C. Start supplemental oxygen
- D. Start oxygen and repeat the pulse oximetry in 20 minutes
Correct Answer: C
Rationale: An O2 saturation of 82% requires immediate supplemental oxygen per orders to correct hypoxia, the priority action.
The nurse manager hears a provider loudly criticize one of the staff nurses within the hearing range of others. The nurse manager's next action should be to
- A. Walk up to the provider and quietly state: 'Stop this unacceptable behavior.'
- B. Allow the staff nurse to handle this situation without interference
- C. Notify the chief of the other administrative persons of a breech of professional conduct
- D. Request an immediate private meeting with the provider and staff nurse
Correct Answer: D
Rationale: Assertive communication respects the needs of all parties to express themselves, but not at the expense of others. The nurse manager needs to protect clients and staff from this display and assist the nurse employee.
A client indicates to the nurse a desire to become pregnant. The client drinks 1-2 glasses of wine on weekends. BMI is 32 kg/m². Which teachings should the nurse reinforce as part of proper preconception health care for this client? Select all that apply.
- A. Avoid eating undercooked hamburgers
- B. Do not have more than 1 alcoholic drink per week
- C. Maintain current BMI
- D. Receive a rubella vaccine at least 3 months before attempting pregnancy
- E. Take 0.4 mg folic acid supplementation daily
Correct Answer: A,B,D,E
Rationale: To optimize preconception health: Avoid undercooked meat to prevent toxoplasmosis; limit alcohol to minimal or none to avoid fetal alcohol syndrome; rubella vaccine prevents congenital rubella syndrome; and folic acid reduces neural tube defects. A BMI of 32 is obese and should be reduced for healthier pregnancy outcomes.
The graduate nurse (GN) is reinforcing education on sitting on and standing up from a chair to a client with crutches. Which instruction by the GN would cause the supervising nurse to intervene?
- A. Hold a crutch in each hand for support when standing up from a chair
- B. Move to the edge of the chair before standing and use the unaffected leg to rise
- C. Touch the back of the unaffected leg to the chair before preparing to sit
- D. Use an armrest or seat for assistance when lowering the body into a chair
Correct Answer: A
Rationale: Holding a crutch in each hand is incorrect as crutches should be placed together on the unaffected side or against a stable surface to free the hands for support when standing. Other instructions (B, C, D) are correct for safe crutch use during sitting and standing.
A client comes to the emergency department for the second time with shortness of breath and substernal pressure that radiates to the jaw. The nurse understands that angina pectoris may be precipitated by which of these factors? Select all that apply.
- A. Amphetamine use
- B. Cigarette smoking
- C. Cold exposure
- D. Deep sleep
- E. Sexual intercourse
Correct Answer: A,B,C,E
Rationale: Angina can be triggered by amphetamines increasing cardiac demand, smoking causing vasoconstriction, cold exposure inducing vasospasm, and sexual intercourse raising heart rate. Deep sleep typically reduces demand.