Nokea
Which of the following statements should the nurse include in the teaching?
- A. A nurse will draw blood from your baby's inner elbow.
- B. Your baby will be given 2 ounces of water to drink prior to the test.
- C. This test should be performed after your baby is 24 hours old.
- D. This test will be repeated when your baby is 2 months old.
Correct Answer: C
Rationale: Newborn genetic screening is most accurate when performed after the baby is 24 hours old.
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The nurse notes that sediment is present in the urine.
- A. Which of the following actions should the nurse take to obtain a sterile urine specimen?
- B. Disconnect the catheter from the collection tubing.
- C. Obtain the specimen from the retention port.
- D. Use the balloon port to obtain the sterile specimen.
- E. Unclamp the collection port below the bag
Correct Answer: B
Rationale: Retention ports allow sterile specimen collection.
A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse should recognize which of the following findings as an indication that the medication has been effective?
- A. Increased blood pressure
- B. Weight Loss
- C. Decreased inflammation
- D. Decreased pain
Correct Answer: B
Rationale: The correct answer is B: Weight Loss. Furosemide is a loop diuretic that helps the body excrete excess fluid and sodium through increased urine output. Therefore, weight loss would indicate that the medication has been effective in reducing the client's fluid volume excess. Increased blood pressure (A) would not be an expected finding as furosemide typically helps lower blood pressure. Decreased inflammation (C) and decreased pain (D) are not directly related to the action of furosemide as a diuretic.
A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following activities should the nurse perform first?
- A. Administer an antiemetic medication.
- B. Evaluate functioning of the suction device.
- C. Provide oral hygiene care
- D. Replace the NG tube.
Correct Answer: B
Rationale: The correct answer is B: Evaluate functioning of the suction device. First, the nurse needs to ensure proper suction to prevent aspiration and maintain airway patency. This step is crucial for the client's safety and well-being. Administering an antiemetic medication (A) may be necessary but not the first priority. Providing oral hygiene care (C) can wait until after ensuring proper suction. Replacing the NG tube (D) is not necessary unless there are signs of tube malfunction.
Which of the following actions is the priority for the nurse to take?
- A. Evaluate the client for orthostatic hypotension.
- B. Monitor the client's urine output.
- C. Obtain the client's laboratory results.
- D. Check the client for nasal congestion
Correct Answer: A
Rationale: Orthostatic hypotension is a potential adverse effect of valsartan overdose.
For each assessment finding, click to specify if the finding is an indication of physical maltreatment, neglect, or financial maltreatment.
- A. Client reports having little food in the house.
- B. Client has bruises in various stages of healing.
- C. Client wears dirty clothing
- D. Client has no access to bank accounts
Correct Answer: A,B,C,D
Rationale: These findings suggest multiple forms of maltreatment.