Nokea
You are about to write an information on the Kardex. There are 4 available writing instruments to use. Which of the following should you use?
- A. Mongol #2
- B. Permanent Ink
- C. A felt or fountain pen
- D. Pilot Pentel Pen marker
Correct Answer: B
Rationale: Permanent ink (B) is required for Kardex to ensure legible, lasting records, per legal standards. Pencil (A) erases, felt/fountain pens (C) smudge, markers (D) fade. B ensures accuracy, making it correct.
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An 8.5 lb, 6 oz infant is delivered to a diabetic mother. Which nursing intervention would be implemented when the neonate becomes jittery and lethargic?
- A. Administer insulin
- B. Administer oxygen
- C. Feed the infant glucose water (10%)
- D. Place infant in a warmer
Correct Answer: C
Rationale: Jitteriness and lethargy suggest hypoglycemia, common in infants of diabetic mothers; glucose water corrects this.
A client with a tracheostomy gets easily frustrated when trying to communicate personal needs to the nurse. The nurse determines that which method for communication may be the easiest for the client?
- A. Use a pad and paper.
- B. Use a picture or word board.
- C. Have the family interpret needs.
- D. Devise a system of hand signals.
Correct Answer: B
Rationale: For a tracheostomy client, a picture or word board (B) is easiest, allowing quick, clear communication without speech. Paper (A) requires literacy and dexterity. Family interpretation (C) is unreliable. Hand signals (D) need setup. B is correct. Rationale: Visual aids bypass vocal limitations, enhancing autonomy, a practical solution per speech therapy standards.
Small for gestational age and large for gestational age infants have polycythemia because of:
- A. Hypocalcemia
- B. Hypoglycemia
- C. Hypoxia
- D. Hypothermia
Correct Answer: C
Rationale: Polycythemia (high red blood cell count) in SGA and LGA infants relates to intrauterine conditions. Hypocalcemia (choice A) affects calcium, not blood cells. Hypoglycemia (choice B) is metabolic, common in both, but unrelated to polycythemia. Hypoxia (choice C) triggers erythropoietin release, increasing RBCs; SGA infants face placental insufficiency, LGA infants (e.g., diabetic mothers) experience transient hypoxia. Hypothermia (choice D) doesn't cause polycythemia. C is correct, as hypoxia drives this adaptation. Nurses monitor hematocrit, manage viscosity risks (e.g., dehydration), and support oxygenation, preventing complications.
When you discover an electrical fire and decide you need a fire extinguisher, you will need to find a fire extinguisher that is rated for which class of fire?
- A. Class A
- B. Class B
- C. Class C
- D. Class E
Correct Answer: C
Rationale: An electrical fire requires a Class C extinguisher, designed for energized electrical equipment like appliances or wiring. Class A suits ordinary combustibles (wood), Class B handles flammable liquids, and Class E isn't standard (often confused with electrical but not U.S.-classified). Using a Class C extinguisher, typically with non-conductive agents like carbon dioxide, ensures safety by avoiding shock while extinguishing. This choice protects both the nurse and client in a healthcare setting, aligning with fire safety protocols.
A client who recently underwent a coronary artery bypass graft is taking furosemide and metoprolol following the procedure. While developing a plan for a heart-healthy diet with the nurse, the client states that diet did not contribute to the heart disease and that the client should be fine just continuing to take the medications. According to the Stages of Change Model, which stage of change is the client in related to diet?
- A. Precontemplation
- B. Contemplation
- C. Preparation
- D. Maintenance
Correct Answer: A
Rationale: The Stages of Change Model tracks behavior shift, and this client's denial of diet's role in heart disease places them in precontemplation. Here, individuals show no intent to change within six months, often resisting evidence like diet's link to atherosclerosis clinging to beliefs that meds alone suffice. Contemplation involves considering change, preparation plans it, and maintenance sustains it none apply, as the client isn't pondering dietary shifts. This stage reflects unawareness or defiance, common post-surgery when focusing on recovery, not prevention. Nursing must gently challenge this, using education like explaining sodium's impact on heart strain to nudge awareness, critical for moving them toward contemplation and eventual heart-healthy habits, preventing further cardiac issues.