Nokea
The physician has ordered a blood test for H. pylori. The nurse should prepare the client by:
- A. Withholding oral intake after midnight
- B. Telling the client that no special preparation is needed
- C. Explaining that a small dose of radioactive isotope will be used
- D. Giving an oral suspension of glucose 1 hour before the test
Correct Answer: B
Rationale: A blood test for H. pylori requires no special preparation, such as fasting or administration of substances.
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The nurse is teaching the mother of a child with attention deficit disorder regarding the use of Ritalin (methylphenidate). The nurse recognizes that the mother understands her teaching when she states the importance of:
- A. Offering high-calorie snacks
- B. Watching for signs of infection
- C. Observing for signs of oversedation
- D. Using a sunscreen with an SPF of 30
Correct Answer: C
Rationale: Ritalin, a stimulant, can cause side effects like insomnia or agitation, not oversedation. The mother's mention of oversedation indicates a misunderstanding, but the question implies correct teaching, so observing for side effects like overstimulation is key.
A child is to receive heparin sodium 5 units per kilogram of body weight by subcutaneous route every 4 hours. The child weighs 52.8 lb. How many units should the child receive in a 24-hour period?
- A. 300
- B. 480
- C. 720
- D. 960
Correct Answer: C
Rationale: Weight: 52.8 lb ÷ 2.2 = 24 kg. Dose: 5 units/kg × 24 kg = 120 units every 4 hours. 24 hours ÷ 4 = 6 doses/day. 120 × 6 = 720 units/day.
Which of the following groups of neonates should be screened for hearing loss?
- A. Premature neonates.
- B. Neonates with risk factors for hearing loss.
- C. Neonates with abnormal Apgar scores.
- D. All neonates.
Correct Answer: D
Rationale: Universal newborn hearing screening is recommended for all neonates (D) to detect hearing loss early. Premature neonates (A), those with risk factors (B), or abnormal Apgar scores (C) are included but not exclusive.
The initial assessment of a newborn reveals a chest circumference of 34 cm and an abdominal circumference of 31 cm. The chest is asymmetrical and breath sounds are diminished on the left side. The nurse should give priority to:
- A. Providing supplemental oxygen by a ventilated mask
- B. Performing auscultation of the abdomen for the presence of active bowel sounds
- C. Inserting a nasogastric tube to check for esophageal patency
- D. Positioning on the left side with head and chest elevated
Correct Answer: A
Rationale: Diminished breath sounds and chest asymmetry suggest a respiratory issue, such as pneumothorax, requiring immediate supplemental oxygen.
The physician has prescribed Novalog insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?
- A. I will make sure I eat breakfast within 10 minutes of taking my insulin.
- B. I will need to carry candy or some form of sugar with me all the time.
- C. I will eat a snack around three o'clock each afternoon.
- D. I can save my dessert from supper for a bedtime snack.
Correct Answer: C
Rationale: Novolog insulin peaks around 1-3 hours after administration, so a snack around 3 PM aligns with the peak to prevent hypoglycemia.