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A nurse is assessing a newborn who is 12 hr old. Which of the following manifestations requires intervention by the nurse? - ANSWERSA. Acrocyanosis of the extremities B. Murmur at the left sternal border C. Substernal chest retractions while sleeping D. Positive Babinski reflex Answer: Substernal chest retractions while sleeping A. Acrocyanosis of the extremities Acrocyanosis of the extremities is an expected manifestation in newborns. Acrocyanosis is a bluish discoloration of the newb...

A nurse is assessing a newborn who is 12 hr old. Which of the following manifestations requires intervention by the nurse? - ANSWERSA. Acrocyanosis of the extremities B. Murmur at the left sternal border C. Substernal chest retractions while sleeping D. Positive Babinski reflex Answer: Substernal chest retractions while sleeping A. Acrocyanosis of the extremities Acrocyanosis of the extremities is an expected manifestation in newborns. Acrocyanosis is a bluish discoloration of the newb...

Exam (elaborations) HESI NCLEX-RN Exam (5th Ed.) - FUNDAMENTALS REVIEW REVISION 2024 2 Exam (elaborations) NCLEX Review HESI Review Revision 2024 3 Exam (elaborations) HESI NCLEX-RN Fundamentals Practice Questions well elaborated 4 Exam (elaborations) HESI/Saunders Online Review for the NCLEX-RN Examination (1 Year) FINAL EXAM 5 Exam (elaborati

The nurse is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition? A. Low serum albumin level B. Low serum transferrin level C. High hemoglobin level D. High cholesterol level - answersA. Rationale: Long-term protein deficiency is required to cause significantly lowered serum albumin levels. Albumin is made by the liver onl...

A nurse in a physician's office is reviewing the medical record of a child with a diagnosis of lactose intolerance. Which of the following findings does the nurse expect to see documented in the child's record? - answersEpisodes of cramping abdominal pain and excessive flatus A client is found to have posttraumatic stress disorder (PTSD) after witnessing a terrorist attack that caused the deaths of hundreds of people. The nurse, developing a plan of care for the client, identifies posttraum...

Taking anticoagulants for the past year Rationale: Anticoagulants (B) increase the risk for bleeding during surgery, which can pose a threat for developing surgical complications. The healthcare provider should be informed that the client is taking such drugs. - ANSWERSThe nurse is assessing several clients prior to surgery. Which factor in a client's history poses the greatest threat for complications to occur during surgery? Leave the catheter in place and reattempt with another catheter...

A nurse is assigned to care for a client with chronic renal failure who is undergoing hemodialysis through an internal arteriovenous (AV) fistula in the right arm. Which of the following interventions should the nurse implement in caring for the client? Select all that apply. A) Assessing the radial pulse in the right extremity B) Using the left arm to take blood pressure readings C) Drawing predialysis blood specimens from the left arm D) Assessing the area over the AV fistula for a bruit a...

What types of procedures should be assigned to professional nurses? - ANSWERSSterile or invasive procedures. Negligence is measured by reasonableness. What question might the nurse ask when determining such reasonableness? - ANSWERSWould a reasonable and prudent nurse act in the same manner under the same circumstances? List the 4 elements that are necessary to prove negligence. - ANSWERSDuty. Failure to protect client again unreasonable risk. Breach of duty. Failure to perform according t...

The nurse assesses a postoperative client whose skin is cool, pale, and moist. The client is very restless and has scant urine output. Oxygen is being administered at 2 L/min, and a saline lock is in place. Which intervention should the nurse implement first? A.Measure the urine specific gravity. B.Obtain IV fluids for infusion per protocol. C.Prepare for insertion of a central venous catheter. D.Auscultate the client's breath sounds. - answersB The client is at risk for hypovolemic shoc...

A client with a diagnosis of preeclampsia suddenly begins to exhibit seizure activity. The first action on the part of the nurse is: Calling the physician Inserting an oral airway Turning the client on her side Noting the time of the seizure - ANSWERSC If seizure activity occurs, the nurse remains with the client and presses the emergency bell for assistance. The client is turned on her side because a side-lying position permits greater circulation through the placenta and helps p...