Nokea
The practical nurse is assisting with care for several newborns in the nursery. Which of the following findings are abnormal and need to be reported to the registered nurse? Select all that apply.
- A. Chest wall retractions
- B. Flaking skin on the feet
- C. Head circumference of 13½ inches (34 cm)
- D. Jaundice of the head and sclera
- E. No documentation of voiding in past 24 hours
Correct Answer: A, D, E
Rationale: Chest retractions (A), jaundice (D), and no voiding (E) are abnormal and require reporting. Flaking skin (B) and head circumference (C) are normal for newborns.
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A client is being discharged after having a coronary artery bypass grafting x5. The client asks questions about the care of chest and leg incisions. Which instructions should the nurse reinforce? Select all that apply.
- A. Report any itching, tingling, or numbness around your incisions
- B. Report any redness, swelling, warmth, or drainage from your incisions
- C. Soak incisions in the tub once a week, then clean with hydrogen peroxide and apply lotion
- D. Wash incisions daily with soap and water in the shower and gently pat them dry
- E. Wear an elastic compression hose on your legs and elevate them while sitting
Correct Answer: A, B, D
Rationale: Reporting sensory changes (A), signs of infection (B), and washing gently (D) promote healing. Soaking and peroxide (C) can disrupt healing, and compression hose (E) are not routinely needed.
The nurse is caring for a client receiving chemotherapy. The client is prescribed filgrastim to improve the function of the immune system. Which finding does the nurse anticipate in response to the medication?
- A. Decrease in serum uric acid
- B. Increase in hemoglobin level
- C. Increase in neutrophil count
- D. Increase in platelet count
Correct Answer: C
Rationale: Filgrastim stimulates neutrophil production, so an increase in neutrophil count (C) is expected. It does not affect uric acid (A), hemoglobin (B), or platelets (D).
Following an arteriogram, the nurse should give priority to:
- A. Allowing the client to rest
- B. Administering O2 via nasal mask
- C. Checking the ECG monitor
- D. Checking the pulses distal to the catheterization site
Correct Answer: D
Rationale: Checking distal pulses ensures adequate circulation post-arteriogram, as the procedure involves arterial puncture, which can lead to complications like hematoma or thrombosis.
A client with borderline personality disorder says to the nurse, 'You're the only one I trust around here. The others don't know what they are doing and they don't care about anyone except themselves. I only want to talk with you.' What is the priority nursing action?
- A. Assign different staff members to care for the client each day
- B. Assign the client's stated preferred nurse to care for the client
- C. Reassure the client that all staff members are competent in their jobs
- D. Reinforce unit guidelines and appropriate boundaries with the client
Correct Answer: D
Rationale: Reinforcing boundaries (D) addresses splitting behavior and maintains therapeutic relationships. Rotating staff (A), assigning the preferred nurse (B), or reassuring competence (C) may reinforce manipulation.
A client with a pyloric obstruction is admitted to the hospital with vomiting. Which of the following blood gases would the nurse expect to see in the client with vomiting?
- A. $\mathrm{pH} 7.33, \mathrm{PCO}_2 30 \mathrm{~mm} \mathrm{Hg}$
- B. $\mathrm{pH} 7.50, \mathrm{PCO}_2 32 \mathrm{~mm} \mathrm{Hg}$
- C. $\mathrm{pH} 7.30, \mathrm{PCO}_2 50 \mathrm{~mm} \mathrm{Hg$
- D. $\mathrm{pH} 7.47, \mathrm{PCO}_2 40 \mathrm{~mm} \mathrm{Hg}$
Correct Answer: B
Rationale: Vomiting causes loss of hydrochloric acid, leading to metabolic alkalosis, indicated by a high pH (7.50) and normal to low PCO2.