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- The nurse is caring for a preterm newborn with nasal flaring, grunting, and sternal retractions. After, administering surfactant, which assessment is the MOST important for the nurse to monitor? A. Arterial blood gases B. Breath sound C. Oxygen saturation D. Respiratory rateThe nurse records an APGAR score of 4 for a newborn. Whatwould be the priority intervention for this newborn?a. No interventions are necessary; this is a normal score.b. Provide respiratory assistance.c. Perform CPR.d. Wait 5 minutes and repeat the scoring process.The nurse has begun a client's assessment and is applying the blood pressure cuff on a client's arm. Which action would be most appropriate? justify the correct and incorrect answer. A. The cuff is wrapped loosely around the arm. B. The cuff is placed about 1 in above the antecubital area. C. The bladder inside the cuff encircles 50% of the arm circumference. D. The nurse can fit three to four fingers under the inflated cuff.
- A nurse is assisting a patient who is 2 days postoperativefrom a cesarean section to sit in a chair. After assisting thepatient to the side of the bed and to stand up, the patient’sknees buckle and she tells the nurse she feels faint. Whatshould the nurse do in this situation?a. Wait a few minutes and then continue the move to the chair.b. Call for assistance and continue the move with the help ofanother nurse.c. Lower the patient back to the side of the bed and pivot herback into bed.d. Have the patient sit down on the bed and dangle her feetbefore moving.The nurse is to perform Leopold's Maneuver on a pregnant patient. What instructions does the nurse give the patient just before the assessment? a. Do not eat the night before the procedure b. Take slow , deep breaths to relieve pain c. Urinate just prior to procedure d. Remain on strict bed rest prior to procedureWhat consideration should the nurse keep in mind regardingthe use of side rails for a confused patient?a. They prevent confused patients from wandering.b. A history of a previous fall from a bed with raised siderails is insignificant.c. Alternative measures are ineffective to prevent wandering.d. A person of small stature is at increased risk for injuryfrom entrapment.
- A nurse is palpating the breast of a woman during an assess-ment. Which technique is performed correctly? a. The nurse starts at the tail of Spence and moves in increas-ing smaller circles. b. The nurse uses the palms of the hands to gently compressthe breast tissue against the chest wall.c. The nurse works in a counterclockwise direction andpalpates from the periphery toward the areola.d. The nurse starts at the inner edge of the breast and palpatesup and down the breast.Older adults often have reduced vital capacity as a result ofnormal physiologic changes. Which nursing interventionwould be most important for the postoperative care of anolder surgical patient specific to this change?a. Take and record vital signs every shift.b. Turn, cough, and deep breathe every 4 hours.c. Encourage increased intake of oral fluids.d. Assess bowel sounds daily.Sandra, 30 year old, primigravida consulted the Obstetrical Unit for a prenatal visit. She complains of abdominal pain and vaginal bleeding. She was diagnosed as Pregnancy Uterine 28 weeks AOG, Gestational Hypertension. Which of the following assessments should the nurse perform first? a. Assess strength of contractions b. Assess serum electrolytes c. Assess urinary output d. Assess fetal heart tones
- A client admitted with shortness of breath and palpitations currently take a antiarrhythmic dronedarone, which action should the nurse take to prevent? A. Measure orthostatic blood pressure B. Obtain a 12 lead ECG reading daily C. Assess the client’s apical pulse daily D. Provide continuous ECG monitoringThe nurse is to administer a medication to a hospitalized client . Which of the following factors should a nurse consider when administering medications to an older adult ? (Select all that apply .) a. Altered peripheral venous tone An increased number of protein -binding sites b. An increased difficulty with the penetration of fat -soluble drugs c. A decline in enzyme production needed for drug metabolism d. An increased gastric emptying time e. A decline in liver function