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, which requires immediate nursing intervention to prevent complications.
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Which vitamin should be administered with INH (isoniazid) in order to prevent possible nervous system side effects?
- A. Thiamine
- B. Niacin
- C. Pyridoxine
- D. Riboflavin
Correct Answer: C
Rationale: Pyridoxine (vitamin B6) is given with isoniazid to prevent peripheral neuropathy, a potential side effect of the medication.
If a client weighs 132 lb and has a caloric requirement of 28 calories per kg of body weight per day, what is the number of calories that the client needs each day to maintain body weight? Record your answer using a whole number.
Correct Answer: 1680
Rationale: Weight = 132 lb/ 2.2 = 60 kg. Calories = 60 kg X 28 cal/kg = 1,680 calories/day.
The nurse is reviewing the lab reports on several clients. Which one should be reported to the physician immediately?
- A. A serum creatinine of 5.2 mg/dL in a client with chronic renal failure
- B. A positive C reactive protein in a client with rheumatic fever
- C. A hematocrit of 52% in a client with gastroenteritis
- D. A white cell count of 2,200 cu/mm in a client taking Dilantin phenytoin
Correct Answer: D
Rationale: A white cell count of 2,200 cu/mm indicates severe leukopenia, a serious side effect of Dilantin, requiring immediate reporting.
The nurse is responsible for performing a neonatal assessment on a fullterm infant. At 1 minute, the nurse could expect to find:
- A. An apical pulse of 100
- B. An absence of tonus
- C. Cyanosis of the feet and hands
- D. Jaundice of the skin and sclera
Correct Answer: C
Rationale: Acrocyanosis (cyanosis of hands and feet) is normal in newborns at 1 minute due to immature circulation.
A client has had diarrhea for the past 3 days. Which acid/base imbalance would the nurse expect the client to have?
- A. Respiratory alkalosis
- B. Metabolic acidosis
- C. Metabolic alkalosis
- D. Respiratory acidosis
Correct Answer: B
Rationale: Prolonged diarrhea leads to loss of bicarbonate, causing metabolic acidosis.