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Which nursing assessment findings indicate normal vital signs in a newborn infant?
- A. Pulse, 112; respiratory rate, 24
- B. Pulse, 124; respiratory rate, 28
- C. Pulse, 144; respiratory rate, 48
- D. Pulse, 164; respiratory rate, 55
Correct Answer: C
Rationale: The normal pulse rate for a newborn is 120 to 160. The normal respiratory rate for a newborn infant is 30 to 60 breaths per minute. Therefore, the other options are incorrect.
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A client with a diagnosis of breast cancer is prescribed exemestane (Aromasin). The nurse should instruct the client to report which of the following side effects immediately?
- A. Hot flashes.
- B. Bone pain.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Bone pain may indicate bone loss or metastasis, a serious side effect of exemestane requiring immediate reporting.
A client with a history of breast cancer is admitted with bone metastases. The nurse should include which of the following in the plan of care?
- A. Administer bisphosphonates as prescribed.
- B. Restrict calcium intake.
- C. Encourage bed rest.
- D. Apply cold packs to affected areas.
Correct Answer: A
Rationale: Bisphosphonates reduce bone resorption and pain in bone metastases.
Identify this cardiac rhythm strip. Fill in the blank. A. Torsades de Pointes B. Accelerated Idioventricular Arrhythmia C. First Degree Atrioventricular Heart Block D. Supraventricular tachycardia
- B. Torsades de Pointes
- C. Accelerated Idioventricular Arrhythmia
- D. First Degree Atrioventricular Heart Block
- E. Supraventricular tachycardia
Correct Answer: C
Rationale: First Degree AV Block is characterized by a prolonged PR interval, assuming the strip shows this pattern.
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min via nasal cannula. The nurse notes the client's oxygen saturation is 88%. What should the nurse do first?
- A. Increase the oxygen flow to 4 L/min.
- B. Notify the physician immediately.
- C. Encourage the client to perform deep breathing exercises.
- D. Reposition the client to a high Fowler's position.
Correct Answer: D
Rationale: Repositioning to a high Fowler's position optimizes lung expansion and improves oxygenation, which is the first non-invasive intervention to try for a COPD client with low oxygen saturation.
A client has a viral (coxsackie B) or trypanosomal (parasite) infection. The nurse should further assess the client for:
- A. Myocarditis.
- B. Myocardial infarction.
- C. Renal failure.
- D. Liver failure.
Correct Answer: A
Rationale: Coxsackie B and trypanosomal infections are associated with myocarditis, an inflammation of the heart muscle, which requires further assessment.