Nokea
A new mother has some questions about PKU.
Which of the following statements made by the nurse is correct regarding PKU?
- A. An amniocentesis is required prior to delivery.
- B. PKU test is performed soon after birth.
- C. PKU is preventable if the mother eats adequate amount of protein during pregnancy.
- D. The effects of PKU are irreversible
Correct Answer: B
Rationale: The PKU test is performed shortly after birth to detect phenylalanine levels.
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The physician has ordered IV replacement of potassium for a patient with severe hypokalemia.
The nurse would administer the IV potassium
- A. by rapid bolus.
- B. diluted in 100 cc over 1 hour.
- C. diluted in 10 cc over 10 minutes.
- D. IV push.
Correct Answer: B
Rationale: Potassium is diluted and infused slowly to prevent cardiac arrhythmias.
The nurse is caring for a 13 year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate post-operative period?
- A. Raise the head of the bed at least 30 degrees
- B. Encourage ambulation within 24 hours
- C. Maintain in a flat position, logrolling as needed
- D. Encourage leg contraction and relaxation after 48 hours
Correct Answer: C
Rationale: Maintain in a flat position, logrolling as needed. The bed should remain flat for at least the first 24 hours to prevent injury.
The nurse is assessing a client with a history of asthma who presents with decreased breath sounds and prolonged expiration. The nurse should prioritize which of the following actions?
- A. Administer a bronchodilator as ordered.
- B. Encourage the client to cough and deep breathe.
- C. Obtain a chest X-ray.
- D. Position the client supine.
Correct Answer: A
Rationale: Decreased breath sounds and prolonged expiration indicate an asthma exacerbation with bronchoconstriction, requiring a bronchodilator to open airways. Coughing (B) is ineffective during an attack, X-rays (C) are diagnostic, and supine positioning (D) worsens breathing.
A nurse is teaching a patient about the use of albuterol (Proventil) for asthma. Which of the following instructions should be included?
- A. Use this medication daily to prevent asthma attacks.
- B. Use this medication only when you feel short of breath.
- C. Use this medication at bedtime.
- D. Use this medication before exercise.
Correct Answer: D
Rationale: Albuterol, a rescue inhaler, is used before exercise to prevent exercise-induced bronchospasm. It’s not for daily prevention, symptom-only use, or bedtime dosing.
A client is sent to the psychiatric unit for forensic evaluation after he is accused of arson. His tentative diagnosis is antisocial personality disorder. In reviewing the client's record, the nurse could expect to find:
- A. A history of consistent employment
- B. A below-average intelligence
- C. A history of cruelty to animals
- D. An expression of remorse for his actions
Correct Answer: C
Rationale: Antisocial personality disorder is associated with a history of cruelty to animals , reflecting disregard for others. Consistent employment and remorse are unlikely. Intelligence is typically average or above.