Nokea
When is the correct time for the nurse to administer the child's morning dose of a combination regular and NPH insulin?
- A. 30 minutes before breakfast is served
- B. 15 minutes before breakfast is served
- C. 30 minutes after breakfast is served
- D. 15 minutes after breakfast is served
Correct Answer: A
Rationale: Regular insulin peaks in 2-4 hours, and NPH peaks in 4-12 hours. Administering the combination 30 minutes before breakfast aligns insulin onset with food intake, controlling postprandial glucose levels effectively.
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The parents are visiting their newborn,who is in the neonatal intensive care unit (NICU) after being diagnosed with a terminal cardiac condition. Which statement best reflects the nurse’s judgment about interventions to promote parental attachment?
- A. Interventions should be delayed until it is certain that the newborn will live.
- B. The parents should be encouraged to provide as much care as possible.
- C. The parents should only be encouraged to touch and name their newborn.
- D. The parents should be assured that they did not do anything to cause this condition.
Correct Answer: B
Rationale: Encouraging parents to provide care promotes attachment aiding coping if the infant dies. Delaying interventions limiting to touch/naming or assuming guilt are less supportive.
The nurse is preparing the parents of a full-term,24-hour-old male newborn for discharge with their infant. Which are the expected discharge criteria that should be met before the infant leaves the hospital? Select all that apply.
- A. Infant vital signs have been normal for the last 12 hours.
- B. The infant has passed at least three meconium stools.
- C. The infant has gained weight at the minimum 100 grams.
- D. The circumcision has had no bleeding for the last 2 hours.
- E. The infant has had six diaper changes in the last 24 hours.
- F. The infant has completed 2 successful consecutive feedings.
Correct Answer: A,D,F
Rationale: Discharge criteria include stable vital signs for 12 hours no circumcision bleeding for 2 hours and two successful feedings. One meconium stool is sufficient weight gain isn’t required and diaper changes aren’t specified.
Which of the following assessment findings would alert the nurse that the child may be exhibiting early signs of sepsis?
- A. Increased level of pain
- B. Disorientation
- C. Decreased urine output
- D. Jitteriness
Correct Answer: B
Rationale: Disorientation can indicate early sepsis in burn patients, reflecting systemic infection affecting the central nervous system. Other signs like fever or tachycardia may also occur, but disorientation is a critical early warning.
Which statement by an adolescent with acne indicates that additional teaching about taking tetracycline hydrochloride (Panmycin) is needed?
- A. I'll take the medication with a full glass of water.
- B. I won't take any antacids with this medication.
- C. I'll take this medication with food.
- D. I'll avoid sun exposure while taking this medication.
Correct Answer: C
Rationale: Tetracycline should be taken on an empty stomach, as food reduces absorption. The statement about taking it with food indicates a need for further teaching.
The nurse reviews the labor and delivery record of the 2-hour-old male newborn and sees this notation: “40 weeks’ gestation,large for gestational (LGA) age.” In response to this information it is most important for the nurse to plan to assess the infant carefully for which condition?
- A. Acrocyanosis
- B. Undescended testicles
- C. Intact clavicles
- D. Hypothermia
Correct Answer: C
Rationale: LGA infants risk birth trauma like fractured clavicles due to macrosomia. Acrocyanosis is normal testicles are typically descended at term and LGA infants are less prone to hypothermia.