Nokea
Which observation in the newborn of a diabetic mother would require immediate nursing intervention?
- A. Crying
- B. Wakefulness
- C. Jitteriness
- D. Yawning
Correct Answer: C
Rationale: Jitteriness in a newborn of a diabetic mother may indicate hypoglycemia, requiring immediate intervention. Crying, wakefulness, and yawning are normal behaviors, so A, B, and D are incorrect.
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Laboratory reference ranges
Hemoglobin
Male: 14.0–18.0 g/dL
(140–180 g/L)
Female: 12.0–16.0 g/dL
(120–160 g/L)
WBC
5000–10,000/mm³
(5–10 × 10⁹/L)
The nurse is collecting data from a client with acute diverticulitis. Which of the following findings would be essential to follow up?
- A. abdominal pain has progressed to the left upper quadrant
- B. hemoglobin of 11.2 g/dL (112 g/L)
- C. lying on side with knees drawn up to abdomen and trunk flexed
- D. WBC count of 12,000/mm³ (12 x 10â¹/L)
Correct Answer: A
Rationale: Pain progressing to the left upper quadrant in diverticulitis is concerning for complications like perforation or abscess, requiring follow-up. Mild anemia and flexed positioning are common, and a moderately elevated WBC is expected in acute inflammation.
A client with iron deficiency anemia is started on ferrous sulfate tablets. The nurse has instructed the client on the appropriate way to take her medication. Which of the following statements indicates that the client understands the nurse's teaching?
- A. I can take my iron tablets with a glass of milk.'
- B. I need to take my iron tablets daily before breakfast.'
- C. Taking my iron tablets before I go to bed will cut down on stomach upset.'
- D. Taking my iron tablets with a glass of orange juice will help me absorb more of the medicine.'
Correct Answer: D
Rationale: Vitamin C (in orange juice) enhances iron absorption. Milk reduces absorption, and timing (breakfast or bedtime) is less critical.
A client comes to the emergency department for the second time with shortness of breath and substernal pressure that radiates to the jaw. The nurse understands that angina pectoris may be precipitated by which of these factors? Select all that apply.
- A. Amphetamine use
- B. Cigarette smoking
- C. Cold exposure
- D. Deep sleep
- E. Sexual intercourse
Correct Answer: A,B,C,E
Rationale: Angina can be triggered by amphetamines increasing cardiac demand, smoking causing vasoconstriction, cold exposure inducing vasospasm, and sexual intercourse raising heart rate. Deep sleep typically reduces demand.
The licensed practical nurse (LPN) is assisting the registered nurse in caring for 4 clients. Which client is at greatest risk for the development of deep venous thrombosis?
- A. 25-year-old client with abdominal pain who smokes cigarettes and takes oral contraceptives
- B. 55-year-old ambulatory client with exacerbation of chronic bronchitis and an elevated hematocrit level
- C. 72-year-old client who had coronary stent placement 2 days ago and has an elevated temperature
- D. 80-year-old client who had surgical repair of a fractured hip 4 days ago
Correct Answer: D
Rationale: An 80-year-old post-hip surgery client is at highest DVT risk due to age, immobility, and recent surgery. Smoking and contraceptives , elevated hematocrit , and stent with fever carry risks but are less immediate.
Which of the following statements describes what the nurse must know in order to provide anticipatory guidance to parents of a toddler about readiness for toilet training?
- A. The child learns voluntary sphincter control through repetition
- B. Myelination of the spinal cord is completed by this age
- C. Neuronal impulses are interrupted by the ganglia
- D. The toddler can understand cause and effect
Correct Answer: B
Rationale: Myelination of the spinal cord is completed by this age, enabling voluntary sphincter control between 18 to 24 months.