Updated Detailed Answers | GRADED A+
Question:
A newborn is placed under fluorescent light as part of the treatment for
physiologic jaundice. During the duration of the newborn's treatment, a nurse
should:
A) keep the newborn completely undressed
B) cover the newborn's closed eyes with patches
C) apply lotion to the newborn's skin
D) keep the newborn on the mother's chest
Answer: B) cover the newborn's closed eyes with patches
Rationale: During phototherapy, eye patches or shields must be used to
protect the newborn's retinas from the bright light. The infant may wear a
diaper but is otherwise undressed. Lotion is not used as it can absorb heat and
cause burns.
Question:
Which of these symptoms should a nurse expect to assess in a client who
develops hypoglycemia?
A) Flushed skin and dry mouth
B) Fruity breath odor
C) Diaphoresis
D) Deep, rapid respirations
Answer: C) Diaphoresis
Rationale: Hypoglycemia (low blood sugar) activates the sympathetic nervous
system, causing symptoms such as diaphoresis (sweating), tremors,
, tachycardia, and anxiety. Flushed skin, dry mouth, fruity breath, and deep
respirations (Kussmaul) are signs of hyperglycemia or DKA.
Question:
A client is eight hours postoperative after a transurethral resection of the
prostate (TURP). Which of these observations, if noted by a nurse, indicates a
complication?
A) Pink-tinged urine in the drainage bag
B) BP 92/60 mm Hg, pulse rate 118/minute
C) Complaints of bladder spasms
D) Presence of small blood clots in the urine
Answer: B) BP 92/60 mm Hg, pulse rate 118/minute
Rationale: Hypotension and tachycardia eight hours post-TURP may indicate
hemorrhage. Pink-tinged urine, small clots, and bladder spasms are expected
findings after TURP. A drop in BP and rise in pulse are signs of hypovolemia and
require immediate attention.
Question:
A nurse should assess a child who has diabetes mellitus (type 1) for symptoms
of hyperglycemia, which include:
A) flushed skin and thirst
B) diaphoresis and pallor
C) tremors and hunger
D) weakness and confusion
Answer: A) flushed skin and thirst
Rationale: Hyperglycemia (high blood sugar) causes symptoms related to
hyperosmolality and dehydration, including flushed, dry skin, intense thirst