Nokea
The parents of a one-month-old boy bring their son to the clinic for evaluation of a possible right dislocated hip.
- A. Which symptom will the nurse observe in a one-month-old with unilateral right hip dislocation?
- B. Limited adduction of the right leg.
- C. Uneven gluteal fold and thigh creases.
- D. Increase in length of the right limb.
- E. Internal rotation of the right leg.
Correct Answer: B
Rationale: Unilateral hip dislocation causes uneven gluteal folds and thigh creases, with deeper and longer folds on the affected side due to hip displacement. Limited abduction (not adduction), shortened limb length, and variable rotation are more typical findings.
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The nurse is caring for a client who is postoperative day 1 after a prostatectomy. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.8°F (38.2°C).
- B. Pain at the incision site.
- C. Urinary output of 200 mL/hour.
- D. Blood-tinged urine.
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-prostatectomy requiring immediate evaluation. Options B, C, and D are expected: incision pain, high urinary output, and blood-tinged urine are normal on day 1.
The nurse is teaching a client with a new diagnosis of hyperlipidemia about atorvastatin (Lipitor). Which of the following statements by the client indicates a need for further teaching?
- A. I should report muscle pain to my doctor.
- B. I should take this medication at night.
- C. I should avoid drinking grapefruit juice.
- D. I should stop this medication if my cholesterol is normal.
Correct Answer: D
Rationale: Stopping atorvastatin when cholesterol is normal is incorrect, as hyperlipidemia often requires lifelong treatment to prevent cardiovascular events. Options A, B, and C are correct: muscle pain may indicate myopathy, nighttime dosing maximizes efficacy, and grapefruit juice increases drug levels.
As a part of a 9 pound full-term newborn's assessment, the nurse performs a dextro-stick at 1 hour post birth. The serum glucose reading is 45 mg/dl. What action by the nurse is appropriate at this time?
- A. Give oral glucose water
- B. Notify the pediatrician
- C. Repeat the test in 2 hours
- D. Check the pulse oximetry reading
Correct Answer: C
Rationale: Repeat the test in 2 hours. This blood sugar is within the normal range for a full-term newborn. Normal values are: Premature infant: 20-60 mg/dl or 1.1-3.3 mmol/L, Neonate: 30-60 mg/dl or 1.7-3.3 mmol/L, Infant: 40-90 mg/dl or 2.2-5.0 mmol/L. Critical values are: Infant: <40 mg/dl and in a Newborn: <30 and >300 mg/dl. Because of the increased birth weight which can be associated with diabetes mellitus, repeated blood sugars will be drawn.
An adult is admitted to the emergency room with a laceration on the forearm and BP=140/74, P=110, and R=36. The client also.adult is admitted to the emergency room with a laceration on the forearm and BP=140/74, P=110, and R=36. The client also complains of tingling around the mouth and in the fingers and toes. What should the nurse expect to do initially?
- A. Administer oxygen
- B. Have the client breathe into a paper bag
- C. Call the physician immediately
- D. Encourage the client to do deep breathing exercises
Correct Answer: B
Rationale: Tachypnea and tingling suggest hyperventilation causing respiratory alkalosis; breathing into a paper bag restores CO2 levels, correcting pH.
The home health care nurse is caring for a 30-year-old woman with type I diabetes mellitus.
- A. What should the nurse expect the physician to order for a client with type I diabetes and morning SMBG readings of 205 mg/dL and 233 mg/dL?
- B. Reduce the client’s diet to 1,500 calorie ADA.
- C. Order 3 additional units of NPH insulin at 10 PM.
- D. Order an additional 10 units of regular insulin at 8 PM.
- E. Eliminate the client’s bedtime snack.
Correct Answer: B
Rationale: Elevated morning blood glucose levels suggest the dawn phenomenon, where blood sugar rises in the early morning due to hormonal changes. Adding 3 units of NPH insulin at 10 PM addresses this by providing longer-acting insulin coverage. Reducing the diet, adding regular insulin, or eliminating the snack does not target the dawn phenomenon effectively.