Nokea
While assessing the vital signs in children, the nurse should know that the apical heart rate is preferred until the radial pulse can be accurately assessed at about what age?
- A. 1 year of age
- B. 2 years of age
- C. 3 years of age
- D. 4 years of age
Correct Answer: B
Rationale: 2 years of age. A child should be at least 2 years of age to use the radial pulse to assess heart rate.
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A 67 year-old client with non-insulin dependent diabetes should be instructed to contact the out-patient clinic immediately if the following findings are present
- A. Temperature of 99.5 degrees Fahrenheit with painful urination
- B. An open, reddened wound on the heel
- C. Insomnia and daytime fatigue
- D. Nausea with 2 episodes of vomiting
Correct Answer: B
Rationale: An open, reddened wound on the heel. When signs of trauma and/or infection occur in their feet, elderly clients who have diabetes and/or vascular disease should seek health care quickly and continue treatment until the problem is resolved. Without treatment, serious infection, gangrene, limb loss, and death may result.
Vital signs
Temperature 100.9 F (38.3 C)
Blood pressure 125/75 mm Hg
Heart rate 109/min
Respirations 15/min
SpO2 100%
The nurse is caring for a postpartum client 36 hours after a cesarean birth who was just diagnosed with postpartum endometritis. Which prescription is priority for the nurse to administer?
- A. Acetaminophen PO PRN for fever
- B. Clindamycin IV every 8 hours
- C. Lactated Ringer IV bolus once
- D. Methylergonovine PO every 4 hours
Correct Answer: B
Rationale: Postpartum endometritis requires prompt antibiotic treatment, so clindamycin IV is the priority to address the infection. Acetaminophen , fluids , and methylergonovine are supportive or unrelated.
An adult comes to the clinic with complaints of frequency and burning on urination. The nurse expects that what test will be ordered for the client?
- A. Clean catch urine for culture and sensitivity
- B. CBC and electrolytes
- C. Cystoscopy
- D. Strain of all urine for calculi
Correct Answer: A
Rationale: Frequency and burning suggest urinary tract infection; a clean catch urine culture identifies the causative organism and antibiotic sensitivity. CBC, cystoscopy, or straining are less immediate.
The licensed practical nurse (LPN) is assisting the registered nurse in caring for 4 clients. Which client is at greatest risk for the development of deep venous thrombosis?
- A. 25-year-old client with abdominal pain who smokes cigarettes and takes oral contraceptives
- B. 55-year-old ambulatory client with exacerbation of chronic bronchitis and an elevated hematocrit level
- C. 72-year-old client who had coronary stent placement 2 days ago and has an elevated temperature
- D. 80-year-old client who had surgical repair of a fractured hip 4 days ago
Correct Answer: D
Rationale: An 80-year-old post-hip surgery client is at highest DVT risk due to age, immobility, and recent surgery. Smoking and contraceptives , elevated hematocrit , and stent with fever carry risks but are less immediate.
The practical nurse is assisting the registered nurse during admission of a client with heart failure-related fluid overload. Which action should be completed first?
- A. Administer oxygen
- B. Assess the client's breath sounds
- C. Initiate cardiac monitoring
- D. Insert a peripheral IV catheter
Correct Answer: B
Rationale: Assessing breath sounds is the first step to evaluate the extent of fluid overload and guide interventions in heart failure. Oxygen , monitoring , and IV insertion follow based on findings.