Nokea
Which of the following is a priority for the nurse to assess when testing the child's urine?
- A. Blood in the urine
- B. Bilirubin in the urine
- C. Ketones in the urine
- D. White blood cells in the urine
Correct Answer: C
Rationale: In DKA, assessing for ketones in the urine is a priority, as ketonuria confirms the presence of ketones, a hallmark of DKA resulting from fat metabolism due to insulin deficiency.
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Which information regarding the use of aspirin is best for the nurse to discuss with the client?
- A. Aspirin should be discarded if not used within 2 years of first being opened.
- B. Aspirin can cause a slight ringing in the ears that will go away eventually.
- C. If aspirin alone does not help, take one or two ibuprofen (Advil) along with the aspirin.
- D. It is best to take aspirin with food to prevent GI upset.
Correct Answer: D
Rationale: Taking aspirin with food reduces the risk of gastrointestinal upset, a common side effect, making it a key point for safe use.
If the nurse collects the following data, which assessment finding best indicates the presence of increased intracranial pressure?
- A. Rapid bilateral pupillary response to light
- B. Tympanic temperature of 97.9°F (36.6°C)
- C. Blood pressure of 150/90 mm Hg
- D. Deep tendon reflexes +2
Correct Answer: C
Rationale: Elevated blood pressure (e.g., 150/90 mm Hg) is a sign of increased intracranial pressure, often part of Cushing's triad (hypertension, bradycardia, irregular respirations), indicating brain compression.
The primiparous client,who delivered a term newborn is a lesbian,achieved her pregnancy via artificial insemination and is in a monogamous relationship with a female partner. Which intervention should the nurse add to the newborn’s care plan?
- A. Avoid acknowledging the client’s lesbian relationship.
- B. Encourage the client’s partner to participate in newborn cares.
- C. Ask the partner to leave the room when the newborn is present.
- D. Avoid telling the newborn’s caregivers about the client’s situation.
Correct Answer: B
Rationale: Encouraging the partner to participate in newborn care shows respect and promotes bonding similar to heterosexual partners. Ignoring the relationship or excluding the partner is disrespectful.
While supervising the LPN,the RN determines that the LPN needs additional instruction in newborn care. Which action by the LPN prompted the nurse’s conclusion?
- A. Assessed the newborn’s heart rate apically
- B. Covered the newborn’s head with a stocking cap
- C. Checked the newborn’s temperature rectally
- D. Positioned the newborn supine while sleeping
Correct Answer: C
Rationale: Rectal temperature checks risk mucosal irritation or perforation. Apical HR assessment stocking caps and supine positioning (to reduce SIDS risk) are correct practices.
Which response by the nurse best explains why aspirin is preferred to acetaminophen (Tylenol) in the treatment of rheumatic fever?
- A. Aspirin controls fever better.
- B. Aspirin prevents infections.
- C. Aspirin relieves joint inflammation.
- D. Aspirin prevents cardiac enlargement.
Correct Answer: C
Rationale: Aspirin is preferred in rheumatic fever due to its anti-inflammatory properties, which relieve joint inflammation and pain associated with polyarthritis. Acetaminophen lacks significant anti-inflammatory effects, making aspirin more effective.