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NGN Laboratory Results (same case of patient who just gave
birth) Which actions are appropriate for the nurse to take at this
time? SATA
A) Keep infant in warmer with bili lights to maintain temp of 97.6F
B) Monitor Temp
C) Continue to monitor glucose level
D) Tell the mother that she will need to discuss this with the neonatologist
E) Explain to the mother that the babys RR needs to be below 60
F) Inform the mother that the baby is stable enought to take out of the warmer
G) Observe for signs of respiratory distress and monitor O2 with pulse ox
A) Keep infant in warmer with bili lights to maintain temp of 97F
E) Explain to the mother that the babys RR need to be below 60
F) Inform the mother that the baby is stable enough to take out of the warmer
G) Observe for signs of respiratory distress and monitor oxygenation by pulse ox
,NGN: a client is a 42 year old female who had a right above the knee amputation
for osteomyelitis. The client has a drain in place in a surgical dressing that will
need to be changed by the surgeon on postop day.
ORDERS: 1400 admit to the surgical floor. Clear liquid diet, advance as tolerated.
Continuous cardio respiratory monitoring. Morphine 1 mg/h IV. Alert surgeon to
signs of bleeding or infection in the surgical site. 1500 docusate sodium 240 mg
orally every a.m. Naloxone 2 mg IV as needed for respiratory depression.
Ibuprofen 600 mg orally every six hours.
A) Provide rescue breaths with a manual ventilation bag.
B) Call for rapid response.
C) Apply oxygen via nasal cannula.
D) Perform chest compressions.
E) Print an electrocardio gram strip.
F) Give naloxone 2 mg IV.
A) Provide rescue breaths with a manual ventilation bag.
B) Call for rapid response.
D) Perform chest compressions.
F) Give naloxone 2 mg IV.
,NGN: 1800: The client is a female neonate born at 37 weeks of gestation to a G 2 P
1
mother, who was diagnosed with gestational diabetes. Following a spontaneous
vaginal birth, she received Apgar scores of seven at one minute and eight at five
minutes. The
client weighs 4036.97g (8lbs 9oz) and appears pink with acrocyanosis and a
moderate amount of subcutaneous fat. She is noted to be slightly jittery at 30min
of age. Axillary
temperature 96F, pulse 140, RR 80. Blood glucose 35, Billy Rubin seven,
fontanelles soft, mongolian spot noted on lower back, Ballard maturity rating 37
weeks.
(Click to highlight notes that demonstrate a positive outcome)
Day 2, 0630: Vitals have remained stable throughout the night. Oxygen 98% on
nasal canal. Mother to breastfeed in the nursery on demand. Able to tolerate
breastmilk.
Glucose after feeding was 60, temp 97.8F, when returned to warmer and bili
light. CXR and echo results were
Glucose after feeding was 60
Direct bili 5
Temp 97.8
Oxygen 98%
Able to tolerate breastmilk
A client with pancreatitis complains of severe epigastric pain, so the nurse
administers a prescribed narcotic analgesic. Ten minutes later, the client insists on
sitting up and
leaning forward. Which intervention should the nurse implement?
A) Rains HOB to 90 degrees
B) Position bedside table so the client can lean across it
C) Place bed in a reverse tren posiiton
D) Encourage rest until the analgesic becomes effective.
B) Position bedside table so the client can lean across it
, The nurse is caring for a client who arrives to the ED with reports of
experiencing dizziness and difficulty walking to the bathroom. The nurse
observes R-sided weakness and sluggish enunciation of speech. The nurse
should immediately take which action?
A) Maintain elevated positioning of the dependent joints on the affected side.
B) Keep the bed in the lowest position and initiate seizure and fall precautions
C) Place an indwelling urinary catheter and measure strict I/Os
D) Start two large-bore IV catheters and review inclusion criteria for IV
fibrinolytic therapy.
D) Start two large-bore IV catheters and review inclusion criteria for IV
fibrinolytic therapy
A male client with a brain tumor is scheduled for a biopsy in the morning. During
the admission procedure, the client has a tonic colonic seizure that last 50
seconds.
Following the seizure, the client is lethargic and confused, and his wife tells the
nurse that her husband has never had a seizure before and has always been
alert and
communicative. Which action should the nurse take?
A) ask the wife to wait outside the room until the nurse can talk with her.
B) keep orienting the client the client to time in space until he is less confused
C) notify the emergency response team of the client's seizure
D) explain the postictal state that usually follows seizures
D) explain the postical state that usually follows seizures