A newborn is having difficulty maintaining a temperature above 98 degrees Fahrenheit and has been placed in a warming isolette. Which action is a nursing priority?
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Solution
Monitor the neonate’s temperature
Option B: When using a warming device the neonate’s temperature should be continuously monitored for undesired elevations.
Option A: The use of heat lamps is not safe as there is no way to regulate their temperature.
Option C: Warming medications and fluids is not indicated.
Option D: While touching with cold hands can startle the infant it does not pose a safety risk.
The nurse is caring for a 2-year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects?
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Solution
Nephrotoxicity
Option C: Nephrotoxicity is a common side effect of calcium disodium edetate, in addition to lead poisoning in general.
Which contraindication should the nurse assess for prior to giving a child immunization?
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Solution
Depressed immune system
Option C: Children who have a depressed immune system related to HIV or chemotherapy should not be given routine immunizations.
Which client is at highest risk of developing a pressure ulcer?
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Solution
75-year-old with left-sided paresthesia and is incontinent of urine and stool
Option C: Risk factors for pressure ulcers include: immobility, absence of sensation, decreased LOC, poor nutrition and hydration, skin moisture, incontinence, increased age, decreased immune response. This client has the greatest number of risk factors.
Included in teaching the client with tuberculosis taking INH about follow-up home care, the nurse should emphasize that a laboratory appointment for which of the following lab tests is critical?
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Solution
Liver function.
Option A: INH can cause hepatocellular injury and hepatitis. This side effect is age-related and can be detected with regular assessment of liver enzymes, which are released into the blood from damaged liver cells.
A nurse is caring for a client who had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires the nurse’s immediate attention?
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Solution
Client reports prickling sensation in the right hand
Option C: Prickling sensation is an indication of compartment syndrome and requires immediate action by the nurse. The other findings are normal for a client in this situation.
Which oxygen delivery system would the nurse apply that would provide the highest concentrations of oxygen to the client?
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Solution
Non-rebreather mask
Option C: The non-rebreather mask has a one-way valve that prevents exhales air from entering the reservoir bag and one or more valves covering the air holes on the face mask itself to prevent inhalation of room air but to allow exhalation of air. When a tight seal is achieved around the mask up to 100% of oxygen is available.
The nurse is assessing the mental status of a client admitted with possible organic brain disorder. Which of these questions will best assess the function of the client’s recent memory?
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Solution
“I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen.”
A victim of domestic violence states, “If I were better, I would not have been beaten.” Which feeling best describes what the victim may be experiencing?
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Solution
Self-blame
Option C: Domestic violence victims may be immobilized by a variety of affective responses, one being self-blame. The victim believes that a change in their behavior will cause the abuser to become nonviolent, which is a myth.
Parents of a 6 month-old breastfed baby ask the nurse about increasing the baby’s diet. Which of the following should be added first?
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Solution
Cereal
Option A: The guidelines of the American Academy of Pediatrics recommend that one new food be introduced at a time, beginning with strained cereal.