Nokea
The perinatal nurse is reviewing telephone messages from clients. The nurse should first telephone the client who is at
- A. 18 weeks gestation, is taking ceftriaxone, and reports mild diarrhea
- B. 22 weeks gestation and is taking acetaminophen twice daily
- C. 28 weeks gestation, is taking metronidazole, and reports dark colored urine
- D. 32 weeks gestation and is taking ibuprofen daily
Correct Answer: D
Rationale: Ibuprofen at 32 weeks gestation is concerning due to risks of premature ductus arteriosus closure and oligohydramnios, requiring immediate follow-up. Mild diarrhea and dark urine with metronidazole are less urgent, and acetaminophen is safe.
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A client admitted to the medical surgical unit was recently weaned from the mechanical ventilator and an IV infusion of lorazepam. The client has been alert and oriented for 24 hours but is now experiencing confusion. The practical nurse assists the registered nurse with the evaluation of new-onset confusion by assessing the client's sense of place and time, difficulty focusing, short-term memory loss, and increasing lethargy. The practical nurse suspects which condition in this client?
- A. Amnesia
- B. Delirium
- C. Dementia
- D. Psychosis
Correct Answer: B
Rationale: New-onset confusion with disorientation, difficulty focusing, memory loss, and lethargy post-ventilation and lorazepam suggests delirium , often seen in ICU patients due to medication withdrawal or critical illness. Amnesia , dementia , and psychosis have different presentations.
The nurse is participating in a staff presentation to review risk factors for skin cancer. Which of the following risk factors should the nurse include? Select all that apply.
- A. Family history of skin cancer
- B. High number of moles
- C. History of severe adolescent acne
- D. Immunosuppressant medication use
- E. Outdoor occupation
Correct Answer: A,B,D,E
Rationale: Risk factors for skin cancer include family history , high number of moles , immunosuppressant use increasing susceptibility, and outdoor occupation due to UV exposure. Severe acne is not a direct risk factor unless associated with specific treatments like radiation.
The nurse is auscultating the lungs in a postoperative client and hears something that sounds like a cellophane bag being wrinkled when the client takes in a breath. How should the nurse record this finding?
- A. Crackles
- B. Stridor
- C. Stertor
- D. Wheezes
Correct Answer: A
Rationale: Crackles, sounding like crinkling cellophane, indicate fluid in alveoli or airway collapse, common post-surgery. Stridor, stertor, and wheezes have different characteristics.
The nurse has just received the shift report. Which one of the following clients should be seen first?
- A. A 14-year-old one day post-appendectomy with a WBC of 6500
- B. A 5-year-old three days post-fracture of the right tibia with a temperature of 101° Fahrenheit
- C. An 11-month-old admitted during the previous shift with dehydration and a hematocrit of 40
- D. An 8-week-old admitted four hours earlier with sub-sternal retractions and an oxygen saturation of 90%
Correct Answer: D
Rationale: Answer D is correct. There is nothing in answer A that indicates the client is unstable. Answer B is a good choice, but the client three days post-fracture may have a slight temperature, so he should be seen second. Answer C is also a good choice, but if the infant with dehydration is stable, the 8-week-old with respiratory distress (sub-sternal retractions and low oxygen saturation) is the most critical and should be seen first.
Vital signs
Temperature 100.9 F (38.3 C)
Blood pressure 125/75 mm Hg
Heart rate 109/min
Respirations 15/min
SpO2 100%
The nurse is caring for a postpartum client 36 hours after a cesarean birth who was just diagnosed with postpartum endometritis. Which prescription is priority for the nurse to administer?
- A. Acetaminophen PO PRN for fever
- B. Clindamycin IV every 8 hours
- C. Lactated Ringer IV bolus once
- D. Methylergonovine PO every 4 hours
Correct Answer: B
Rationale: Postpartum endometritis requires prompt antibiotic treatment, so clindamycin IV is the priority to address the infection. Acetaminophen , fluids , and methylergonovine are supportive or unrelated.