Nokea
Which of the following nursing actions has the HIGHEST priority in caring for the client with hypoparathyroidism?
- A. Develop a teaching plan.
- B. Plan measures to deal with cardiac dysrhythmias.
- C. Take measures to prevent a respiratory infection.
- D. Assess laboratory results.
Correct Answer: B
Rationale: cardiac dysrhythmias related to low serum calcium would be the highest priority
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A nurse admits a 3 week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be most consistent with this diagnosis?
- A. Gestational age assessment suggested growth retardation
- B. Meconium was cleared from the airway at delivery
- C. Phototherapy was used to treat Rh incompatibility
- D. The infant received mechanical ventilation for 2 weeks
Correct Answer: D
Rationale: The infant received mechanical ventilation for 2 weeks. Bronchopulmonary dysplasia is often caused by prolonged mechanical ventilation.
A mother wants to switch her 9 month-old infant from an iron-fortified formula to whole milk because of the expense. Upon further assessment, the nurse finds that the baby eats table foods well, but drinks less milk than before. What is the best advice by the nurse?
- A. Change the baby to whole milk
- B. Add chocolate syrup to the bottle
- C. Continue with the present formula
- D. Offer fruit juice frequently
Correct Answer: C
Rationale: Continue with the present formula. Switching to whole milk before 12 months can lead to allergies and lactose intolerance.
A client with a total knee replacement returns from surgery. Which finding requires immediate nursing intervention?
- A. There is $30 \mathrm{~mL}$ of bloody drainage from the Davol drain.
- B. The continuous passive motion machine is set on $90^{\circ}$ flexion.
- C. The client is unable to ambulate to the bathroom.
- D. The client is complaining of muscle spasms.
Correct Answer: B
Rationale: A 90° flexion setting on the CPM machine is too aggressive post-surgery, risking injury, and requires immediate adjustment. Drainage , non-ambulation , and spasms are expected or less urgent.
The nurse is performing physical assessments on adolescents. What finding would the nurse anticipate concerning female growth spurts?
- A. They occur about 2 years earlier than for males.
- B. They begin about the same time for males.
- C. They begin just prior to the onset of puberty.
- D. They are characterized by an increase in height of 4 inches each year.
Correct Answer: A
Rationale: They occur about 2 years earlier than for males. Females experience a growth spurt about 2 years earlier than their male peers.
The nurse is caring for a client with a suspected pulmonary embolism.
- A. Which diagnostic Test should the nurse anticipate for a client with a suspected pulmonary embolism?
- B. Chest X-ray.
- C. D-dimer blood Test .
- D. Electrocardiogram (ECG).
- E. Arterial blood gas (ABG).
Correct Answer: B
Rationale: A D-dimer blood Test is a sensitive screening tool for pulmonary embolism, detecting fibrin degradation products from a clot. Chest X-ray and ECG are non-specific, and ABG assesses oxygenation but not the diagnosis directly.