Nokea
When assessing a 2-month-old infant, the nurse feels a 'click' when abducting the infant's left hip. Which of the following should the nurse do next?
- A. Document the finding as normal for a 2-month-old.
- B. Check the lengths of the femurs to determine if they are equal.
- C. Instruct the mother to keep the leg in an adducted position.
- D. Reschedule the child for a follow-up assessment in 3 weeks.
Correct Answer: B
Rationale: A 'click' during hip abduction suggests developmental dysplasia of the hip, so checking femur lengths helps confirm asymmetry for further evaluation.
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A client is experiencing symptoms of early alcohol withdrawal. The client's blood pressure is 150/85 mm Hg and the pulse is 98 bpm. The nurse should:
- A. Administer lorazepam (Ativan).
- B. Apply arm and leg restraints.
- C. Assign an unlicensed assistive personnel to sit with the client.
- D. Notify the physician.
Correct Answer: D
Rationale: Notifying the physician is the priority to obtain orders for managing alcohol withdrawal symptoms, which may require medications like lorazepam.
The nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings indicates a complication of TPN?
- A. Blood glucose of 200 mg/dL.
- B. Temperature of 99°F.
- C. Weight gain of 1 lb per week.
- D. Clear breath sounds.
Correct Answer: A
Rationale: Hyperglycemia (blood glucose of 200 mg/dL) is a common complication of TPN due to high dextrose content, requiring insulin adjustments.
To improve the accuracy of client identification, the nurse must use at least two identifiers when providing care, treatment, or services. Which of the following are appropriate? Select all that apply.
- A. Room number.
- B. Bed number.
- C. Medical record number.
- D. Name band.
- E. Social security number.
Correct Answer: C,D,E
Rationale: Appropriate identifiers include medical record number, name band, and social security number, as they are unique to the client. Room and bed numbers are not reliable identifiers.
The nurse is caring for a client with a burn injury covering 30% of the body. Which fluid should the nurse expect to administer?
- A. Normal saline
- B. Lactated Ringer's
- C. 5% dextrose
- D. Albumin
Correct Answer: B
Rationale: Lactated Ringer's is the preferred fluid for burn resuscitation per the Parkland formula, restoring volume and electrolytes without causing hemolysis.
The nurse is performing Leopold's maneuvers on a woman who is in her eighth month of pregnancy. The nurse is palpating the uterus as shown by the following maneuvers is the nurse performing?
- A. First maneuver.
- B. Second maneuver.
- C. Third maneuver.
- D. Fourth maneuver.
Correct Answer: C
Rationale: The third Leopold's maneuver involves palpating the lower uterus to determine the presenting part, typically performed in the eighth month to assess fetal position.