Nokea
A student nurse obtaining an infant's vital signs.
Which of the following actions should the student nurse complete FIRST?
- A. Take an axillary temperature to minimize use of invasive procedures.
- B. Count respirations for 15 seconds and multiply the number by 4.
- C. Count respirations for a minute prior to arousing the infant.
- D. Use a stethoscope with a one-and-a-half-inch diaphragm to count the apical pulse.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) inappropriate to use probe to take axillary temperature (2) should count for a full minute (3) correct-respirations should be counted for one full minute prior to arousing the infant with a temperature probe or stethoscope (4) after infant is stimulated, crying may interfere with accurate evaluation of respirations
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A two-day-old infant in the newborn nursery does not appear interested in taking formula from the mother or the nurse.
An appropriate nursing diagnosis is high risk for
- A. impaired swallowing.
- B. failure to thrive.
- C. fluid volume deficit.
- D. altered health maintenance.
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) no information about swallowing provided with question (2) this is a medical diagnosis not a nursing diagnosis (3) correct-may become dehydrated (4) not specific for problem described
The physician prescribes estrogen (Premarin) 0.625 mg daily for a 43-year-old woman. The nurse knows which of the following symptoms is a common initial side effect of this medication?
- A. Nausea.
- B. Visual disturbances.
- C. Tinnitus.
- D. Ataxia.
Correct Answer: A
Rationale: common at breakfast time; will subside after weeks of medication use; take after eating to reduce incidence
The nurse is teaching a client how to care for a colostomy. Which factor indicates that the client needs more instruction?
- A. The client says, 'I will change the bag as soon as it gets full.'
- B. The client is observed irrigating the colostomy while sitting on the toilet.
- C. The client positions the irrigating solution container at shoulder level.
- D. The client places a chlorophyll tablet in the drainage bag.
Correct Answer: B
Rationale: Irrigating while sitting on the toilet risks contamination; irrigation should be done in a controlled setting, indicating a need for further instruction.
A toddler with Tetralogy of Fallot is hospitalized with a diagnosis of pneumonia. During the nursing assessment, the child develops a hypoxic episode. The nurse should:
- A. Provide the child his favorite toy.
- B. Place the child in a supine position.
- C. Pick the child up and comfort him.
- D. Place the child in knee chest position.
Correct Answer: D
Rationale: The knee-chest position increases systemic vascular resistance, reducing right-to-left shunting in Tetralogy of Fallot during hypoxia. Toys or comforting do not address hypoxia. Supine position may worsen shunting.
The physician prescribes sucralfate (Carafate) 1 gm PO tid and 2 Maalox tablets tid for a 50-year-old man in the outpatient clinic.
The client asks the nurse when to take these medications. The nurse should advise the man to take
- A. the Carafate and the Maalox 1 hour ac.
- B. the Maalox 1 hour ac and the Carafate 1 hour pc.
- C. the Carafate and the Maalox 2 hours pc and hs.
- D. the Carafate 1 hour ac and the Maalox 1 hour pc.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) Maalox (antacids) decreases bonding to GI mucosa, don't give within 30 minutes of each other (2) Carafate best results on empty stomach, antacids decrease bonding to GI mucosa, so don't give within 30 minutes of each other (3) antacids decrease bonding to GI mucosa, so don't give within 30 minutes of each other (4) correct-Carafate has best results on empty stomach