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A nurse is caring for a newborn whose parent asks why her baby is receiving vitamin K. The nurse should
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explain to the parents that the newborn should receive vitamin K to prevent which of the following?
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A. Bleeding
B. Potassium deficiency k
C. Infection
D. Hyperbilirubinemia - CORRECT RESPONSE ✔✔A. Bleeding k k k k k
Newborns should receive vitamin K at birth because they have low levels of vitamin K, which can lead to
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bleeding. Vitamin K does not prevent potassium deficiency, infection, or hyperbilirubinemia in a
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newborn.
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A charge nurse is observing a newly licensed nurse administer enteral feedings via NG tube. Which of the
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following actions by the newly licensed nurse indicates an understanding of the procedure?
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A. Instills 100 mL of air into the NG tube after checking for residual.
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B. Flushes the NG tube with 0.9% sodium chloride irrigation every 2 hr.
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C. Adds 20 mL of blue dye to each feeding to help detect aspiration.
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D. Keeps the head of the bed elevated to 45° for 1 hr after feedings. - CORRECT RESPONSE ✔✔D. Keeps
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the head of the bed elevated to 45° for 1 hr after feedings.
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The nurse should keep the client's head elevated to 45° for 1 hr after feedings to decrease the risk for
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aspiration. The nurse should inject 10 to 30 mL of air into the NG tube before checking residual to clear the
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tube of any feeding. Instilling excessive air into the tube can cause abdominal distention and
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discomfort. The nurse should use 20 mL of tap water to flush the NG tube before and after each feeding.
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Using 0.9% sodium chloride irrigation can lead to hypernatremia. The nurse should avoid adding dye to the
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feeding to detect aspiration because using dye can increase the risk of death.
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A nurse is teaching a client about foods high in vitamin A. Which of the following foods should the nurse
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recommend as having the highest amount of vitamin A?
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A. 1 medium raw carrot
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B. 1/2 cup cooked spinach
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C. 1/2 cup cooked butternut squash
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D. 1 cup sliced cantaloupe - CORRECT RESPONSE ✔✔A. 1 medium raw carrot
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The nurse determines that carrots are the best source to recommend because 1 medium raw carrot
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contains 2,025 mcg/dL of vitamin A. The nurse should recommend a different food, because 1/2 cup
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cooked spinach contains 737 mcg/dL, 1/2 cup cooked butternut squash contains 714 mcg/dL, and 1 cup
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sliced cantaloupe contains 516 mcg/dL of vitamin A.
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An RN is planning care for a group of clients and is working with a licensed practical nurse (LPN) and an
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assistive personnel (AP). Which of the following tasks should the RN delegate to the LPN?
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A. Collection of a stool specimen
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B. Preparation of a client's postoperative bed
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C. Administration of a unit of packed RBCs
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D. Insertion of a nasogastric tube - CORRECT RESPONSE ✔✔D. Insertion of a nasogastric tube
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The nurse should delegate the insertion of a nasogastric tube to the LPN because this task is within the
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LPN's scope of practice. The nurse should delegate collection of a stool specimen and preparation of a
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client's postoperative bed to an AP because these tasks are within the AP's scope of practice. The RN
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should administer packed RBCs because this task is not within the scope of practice for an LPN or AP.
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A nurse on a medical-surgical unit is caring for a client prior to a surgical procedure. Which of the
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following findings should indicate to the nurse that the client has the ability to sign the informed
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consent?
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A. The client's partner tells the nurse that the client understands the procedure.
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B. The nurse locates the provider's prescription for the surgical procedure.
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C. The nurse witnesses the provider's explanation of the procedure.
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D. The client is able to accurately describe the upcoming procedure. - CORRECT RESPONSE ✔✔D. The
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client is able to accurately describe the upcoming procedure.
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The ability of the client to accurately describe the upcoming procedure indicates that the provider
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adequately informed the client, and that the client has the ability to sign the informed consent. The client
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can tell his partner that he understands the procedure, but the nurse must speak directly to the client to
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ensure that the client understands what the provider has told him before being certain that the client has
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the ability to sign the form. A written prescription for a surgical procedure does not ensure that the
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provider has explained the procedure to the client or that the client has the knowledge to give informed
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consent. Even though the provider has explained the procedure to the client, the nurse cannot assume that
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the client understands the information the provider gave.
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A nurse is caring for a client who is receiving total parenteral nutriton (TPN) solution by continuous IV i
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nfusion at 60 mL/hr. The nurse discovers the infusion pump has stopped working. Which of the followin g
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actions should the nurse take while waiting for a new infusion pump?
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A. Administer the TPN solution at the same rate using manual drip tubing.
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B. Offer the client oral fluids in place of the TPN solution.
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C. Infuse 0.9% sodium chloride solution usingAmanual drip tubing at 30 mL/hr.
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D. ProvideAdextroseA10%AinAwaterAsolutionAusingAmanualAdripAtubingAatA60AmL/hr.A-
ACORRECTARESPONSEAA✔✔D.AProvideAdextroseA10%AinAwaterAsolutionAusingAmanualAdripAtubingAatA60AmL
/hr.
The nurse should use an infusion pump when administering TPN solution to ensure accurate dosage an
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kd should taper the infusion rate before discontinuing the solution to prevent hypoglycemia. If the nurse
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is unable to continue the TPN infusion by infusion pump, the nurse should use manual drip tubing to i
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nfuse dextrose 10% in water at the same rate as the TPN solution. The nurse should only administer th
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ke TPN solution using an infusion pump to deliver it at a controlled rate. The nurse must continue to pro
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vide fluids by IV infusion to a client who has been receiving a continuous TPN infusion to prevent rebou
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nd hypoglycemia. The nurse should infuse an IV solution that will maintain adequate blood glucose leve
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ls, 0.9% sodium chloride does not have adequate glucose.
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AAnurse is assessing a client who has schizophrenia and is taking chlorpromazine. Which of the followin g
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findings is the priority for the nurse to report the provider?
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A. TemperatureA39.4°ACA(103°AF)
B. Headache
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C. Constipation
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D. Vomiting - CORRECT RESPONSE ✔✔A. Temperature 39.4° C (103° F)
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The greatest risk to the client is injury from neuroleptic malignant syndrome, a potentially life-
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threatening adverse effect of chlorpromazine in which the client can have a high temperature, dysrhyth
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mia, decreased level of consciousness, and labile blood pressure. Therefore, the priority finding for the
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nurse report to the provider is hyperpyrexia. Headache, constipation, and vomiting are common advers e
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effects of chlorpromazine. The nurse should report the headache and vomiting to the provider and re
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quest analgesia and an antiemetic, respectively. The nurse should encourage the client to increase fiber
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and fluid intake as well as activity for constipation.
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A nurse is teaching the parent of a school-
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age child about administering ear drops. Which of the following responses by the parent indicates an u
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nderstanding of the teaching?
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A. "I should administer the ear drops as soon as I remove them from the refrigerator."
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B.A"IAshouldApullAtheAtopAofAherAearAupwardAandAbackAwhileAinstillingAtheAmedication."
C. "I should massage behind her ear after I instill the drops."
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D. "I should have her lie on the affected side for a few minutes after I put the drops in the ear." -
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CORRECT RESPONSE ✔✔B. "I should pull the top of her ear upward and back while instilling the medi
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cation."
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The nurse should instruct the parent to pull the pinna upward and back in children older than 3 years o
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kf age to straighten the ear canal and allow the medication to reach the entire canal. For children young
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er than 3 years of age the parent should gently pull the pinna downward and back. The nurse should in
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struct the parent to allow otic medication she stores in the refrigerator to warm to room temperature p
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rior to administration to prevent dizziness and pain. The nurse should instruct the parent to gently mas
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sage the tragus on the area anterior to the ear to allow the medication to reach the entire canal. The n
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urse should instruct the parent to have the child remain lying on the unaffected side for a few minutes
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after instilling the medication to allow the medication to remain in the ear canal.
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AAnurse is assessing a client who is experiencing autonomic dysreflexia. Which of the following findings
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should the nurse expect? (Select all that apply.)
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A. Nystagmus
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B.AFacialAflushing
C. Diplopia
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D. Nasal congestion
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E. Headache - CORRECT RESPONSE ✔✔B. Facial flushing
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D. Nasal congestion
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E. Headache
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The nurse should expect a client who has autonomic dysreflexia to have facial flushing, nasal congestio n,
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and a severe headache. The nurse should expect a client who has autonomic dysreflexia to have blur red
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vision (not nystagmus) and blurred vision (not diplopia).
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