Nokea
Which one of the following infants needs a further assessment of growth?
- A. 4-month-old: birth weight 7 lb, 6 oz; current weight 14 lb, 4 oz
- B. 2-week-old: birth weight 6 lb, 10 oz; current weight 6 lb, 12 oz
- C. 6-month-old: birth weight 8 lb, 8 oz; current weight 15 lb
- D. 2-month-old: birth weight 7 lb, 2 oz; current weight 9 lb, 6 oz
Correct Answer: B
Rationale: The 2-week-old has only gained 2 oz since birth, which is inadequate (normal is 0.5-1 oz/day), indicating a need for growth assessment.
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Which of the following findings is associated with right-sided heart failure?
- A. Shortness of breath
- B. Nocturnal polyuria
- C. Daytime oliguria
- D. Crackles in the lungs
Correct Answer: B
Rationale: Nocturnal polyuria is a classic sign of right-sided heart failure due to fluid redistribution when lying down.
The client with a recent liver transplant asks the nurse how long he will have to take an immunosuppressant. Which response would be correct?
- A. 1 year
- B. 5 years
- C. 10 years
- D. The rest of his life
Correct Answer: D
Rationale: Lifelong immunosuppression is required post-transplant to prevent organ rejection.
The RN is making assignments on a 12-bed unit. Staff consists of one RN and two certified nursing assistants. Which client should be self-assigned?
- A. A client receiving decadron for emphysema
- B. A client with chest trauma and a new onset of hemoptysis
- C. A client with rib fractures and an O2 saturation of 93%
- D. A client 2 days post-operative lung surgery with a pulse oximetry of 92%
Correct Answer: B
Rationale: New-onset hemoptysis in a chest trauma client indicates potential serious complications (e.g., pulmonary hemorrhage) requiring RN assessment and intervention.
The client is admitted to the emergency room with shortness of breath, anxiety, and tachycardia. His ECG reveals atrial fibrillation with a ventricular response rate of 130 beats per minute. The doctor orders quinidine sulfate. While he is receiving quinidine, the nurse should monitor his ECG for:
- A. Peaked P wave
- B. Elevated ST segment
- C. Inverted T wave
- D. Prolonged QT interval
Correct Answer: D
Rationale: Quinidine can prolong the QT interval, increasing the risk of torsades de pointes.
The nurse is assisting the physician with removalCus of a central venous catheter. To facilitate removal, the nurse should instruct the client to:
- A. Perform the Valsalva maneuver as the catheter is advanced
- B. Turn his head to the left side and hyperextend the neck
- C. Take slow, deep breaths as the catheter is removed
- D. Turn his head to the right while maintaining a sniffing position
Correct Answer: C
Rationale: Taking slow, deep breaths during central venous catheter removal minimizes the risk of air embolism.