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When performing a newborn assessment, the nurse should measure the vital signs in the following sequence:
- A. Pulse, respirations, temperature
- B. Temperature, pulse, respirations
- C. Respirations, temperature, pulse
- D. Respirations, pulse, temperature
Correct Answer: A
Rationale: When performing a newborn assessment, it is important to measure the vital signs in the sequence of pulse, respirations, and temperature. This sequence is recommended because measuring the pulse first provides immediate information on the baby's cardiovascular status, followed by respirations to assess respiratory function, and ending with temperature which can be influenced by the other vital signs. This comprehensive approach helps ensure all vital signs are assessed accurately and in a logical order.
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A 3-year-old child from a suburban community presents with vomiting, diarrhea, and blurred vision. Physical examination reveals an afebrile child with pinpoint pupils, salivation, and muscular fasciculations. The child's lawn was treated yesterday for insects. Which of the following tests will establish the correct diagnosis?
- A. Blood-lead level
- B. 24-hour urine mercury level
- C. Plasma cholinesterase level
- D. Urine malathion level
Correct Answer: C
Rationale: The symptoms suggest organophosphate poisoning, which can be confirmed by measuring plasma cholinesterase levels, as organophosphates inhibit this enzyme.
The nurse is instructed to perform preoperative preparation for the management of a client with malignant tumors. Which of the ff is the most important factor of the nursing management plan?
- A. Insertion of an ostomy pouch
- B. Assessing the symptoms of peritonitis
- C. Maintaining the integrity of the urinary
- D. Insertion of a nasogastric tube diversion procedure
Correct Answer: B
Rationale: Peritonitis is a serious and potentially life-threatening condition that can occur as a complication of malignant tumors. It is characterized by inflammation of the lining of the abdomen and can result in severe abdominal pain, tenderness, fever, and other symptoms. Prompt assessment of peritonitis symptoms is crucial for early detection and intervention to prevent further complications and improve patient outcomes. Assessing for peritonitis symptoms should be the priority in the nursing management plan to ensure timely and appropriate care for the client with malignant tumors.
Why are rectal temperatures not recommended in the newborn?
- A. They are inaccurate.
- B. They do not reflect core body temperature.
- C. They can cause perforation of rectal mucosa.
- D. They take too long to obtain an accurate reading.
Correct Answer: C
Rationale: Rectal temperatures are not recommended in newborns because they can potentially cause perforation of the rectal mucosa. Newborns have fragile, delicate tissues in the rectal area, and the insertion of a rectal thermometer may lead to injury or damage to the mucosal lining. It is important to exercise caution and use alternative methods for taking temperatures in newborns to avoid any harm or discomfort.
The laboratory results of a patient with disseminated intravascular coagulation are likely to include:
- A. decreased levels of fibrin split products.
- B. increased levels of fibrinogen.
- C. increased platelet counts.
- D. prolonged prothrombin and partial thromboplastin times.
Correct Answer: D
Rationale: DIC leads to prolonged clotting times due to consumption of clotting factors and platelets.
The laboratory results of a patient with disseminated intravascular coagulation are likely to include:
- A. decreased levels of fibrin split products.
- B. increased levels of fibrinogen.
- C. increased platelet counts.
- D. prolonged prothrombin and partial thromboplastin times.
Correct Answer: D
Rationale: DIC leads to prolonged clotting times due to consumption of clotting factors and platelets.