When assessing the newborn’s mouth, look forthe presence of thrush (Candida albicans), whichare white patchy areas on the tongue or gums thatcannot be removed with a washcloth; these may bepainful.
1 / 6
The postpartum nurse is providing instructions tothe mother of a newborn with hyperbilirubinemiawho is being breast-fed. The nurse should providewhich instruction to the mother?
2 / 6
The mother of a newborn calls the clinic andreports that when cleaning the umbilical cord,she noticed that the cord was moist and that dischargewas present. What is the most appropriatenursing instruction for this mother?
3 / 6
The nurse in a neonatal intensive care unit (NICU)receives a telephone call to prepare for the admissionof a 43-week gestation newborn with Apgarscores of 1 and 4. In planning for admission of thisnewborn, what is the nurse’s h ighest priority?
4 / 6
The nurse is assessing a newborn after circumcisionand notes that the circumcised area is red with asmall amount of bloody drainage. Which nursingaction is most appropriate?
5 / 6
The nurse in a newborn nursery is monitoring apreterm newborn for respiratory distress syndrome.Which assessment findings should alertthe nurse to the possibility of this syndrome?Select all that apply.
6 / 6
The nurse assisted with the birth of a newborn.Which nursing action is most effective in preventingheat loss by evaporation?
Your score is
The average score is 38%
An insufficient supply of insulin in a client withdiabetes mellitus can result in metabolic acidosis knownas diabetic ketoacidosis.
The nurse is caring for a client with diabetic ketoacidosisand documents that the client is experiencingKussmaul’s respirations. Which patterns did thenurse observe? Select all that apply.
The nurse is caring for a client with a nasogastrictube that is attached to low suction. The nurse monitorsthe client for manifestations of which disorderthat the client is at risk for?
The nurse is caring for a client having respiratorydistress related to an anxiety attack. Recentarterial blood gas values are pH ¼7.53,PaO2¼72 mm Hg (72 mm Hg), PaCO2¼32 mm Hg(32 mm Hg), and HCO3À ¼28 mEq/L(28 mmol/L).Which conclusion about the client should thenurse make?
A client with a 3-day history of nausea and vomitingpresents to the emergency department. The client ishypoventilating and has a respiratory rate of 10breaths/minute. The electrocardiogram (ECG) monitordisplays tachycardia,with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nursereviews the results, expecting to note which finding?
The nurse reviews the arterial blood gas results of aclient and notes the following: pH 7.45, PaCO2 of30 mm Hg (30 mm Hg), and HCO3 À of 20 mEq/L(20 mmol/L). The nurse analyzes these results asindicating which condition?
1.You are taking care of a patient with severe COPD. What type of diet would best suit this patient's needs?
The average score is 36%
Fundamentals of Care
1 / 5
The nurse notes documentation that a client isexhibiting Cheyne-Stokes respirations. On assessmentof the client, the nurse should expect to notewhich finding?
2 / 5
The nurse is testing the extraocular movementsin a client to assess for muscle weakness in theeyes. The nurse should implement which assessmenttechnique to assess for muscle weakness inthe eye?
3 / 5
While performing a cardiac assessment on a clientwith an incompetent heart valve, the nurse auscultatesa murmur. The nurse documents the findingand describes the sound as which?
4 / 5
A client diagnosed with conductive hearing lossasks the nurse to explain the cause of the hearingproblem. The nurse plans to explain to the clientthat this condition is caused by which problem?
5 / 5
The nurse is performing a neurological assessmenton a client and elicits a positive Romberg’s sign.The nurse makes this determination based onwhich observation?
The average score is 20%
FLUID & ELECTROLYTES
The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply
The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client’s record and determines that the client is at risk for developing the potassium deficit because of which situation?
The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present?
The nurse reviews a client’s electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply
Potassium chloride intravenously is prescribed for a client with hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Select all that apply.
The average score is 19%
Administration of Blood Products
Packed red blood cells have been prescribed for a female client with a hemoglobin level of 7.6 g/dL (76 mmol/L) and a hematocrit level of 30% (0.30). The nurse takes the client’s temperature before hanging the blood transfusion and records 100.6 °F (38.1 °C) orally. Which action should the nurse take?
A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client’s blood pressure is 90/50 mm Hg from a baseline of 125/78 mm Hg. The client’s temperature is 100.8 °F (38.2 °C) orally from a baseline of 99.2 °F(37.3 °C) orally. The nurse determines that the client may be experiencing which complication of a blood transfusion?
The nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse should ask which initial question?
The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken next?
A client has received a transfusion of platelets. Thenurse evaluates that the client is benefiting mostfrom this therapy if the client exhibits whichfinding?
The average score is 33%
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