A nurse is caring for a client who is postpartum and asks the nurse why her newborn received a vitamin K injection.
The nurse should explain that the injection is administered in order to prevent which of the following complications in the newborn?

Sepsis.

Tachypnea.

Bleeding.

Jaundice.

Answer and Explanation

The Correct Answer is C

The nurse should explain that the injection is administered in order to prevent vitamin K deficiency bleeding (VKDB) in the newborn. Vitamin K is needed for blood clotting, but newborn babies have very low levels of vitamin K in their bodies at birth because only small amounts of the vitamin pass through the placenta and breast milk. VKDB can cause life-threatening bleeding in various parts of the body, such as the brain, intestines, or skin. VKDB can be classified into early-onset, classic, or late- onset depending on the time of presentation after birth. The most effective way to prevent VKDB is to give a single intramuscular dose of 0.5 to 1 mg of vitamin K to all newborn infants within 6 hours of birth.

Choice A is wrong because sepsis is not caused by vitamin K deficiency, but by bacterial infection.

Choice B is wrong because tachypnea is not caused by vitamin K deficiency, but by respiratory distress or other conditions.

Choice D is wrong because jaundice is not caused by vitamin K deficiency, but by high levels of bilirubin in the blood.

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Correct Answer is D

Explanation

Dysrhythmia is an abnormal heart rhythm that can be a sign of severe lithium toxicity.

Lithium toxicity can occur when a person takes too much lithium, a mood- stabilizing medication used to treat bipolar disorder and major depressive disorder.

Choice A is wrong because hypoglycemia is not a symptom of lithium toxicity. Hypoglycemia is low blood sugar that can cause symptoms such as shakiness, sweating, hunger, and confusion.

Choice B is wrong because excess salivation is not a symptom of lithium toxicity. Excess salivation can be caused by various factors, such as infections, medications, or nerve damage.

Choice C is wrong because urinary retention is not a symptom of lithium toxicity. Urinary retention is the inability to empty the bladder completely, which can cause pain, discomfort, and infection. Lithium toxicity can actually cause increased urine output, not decreased.

Normal ranges for blood lithium levels are 0.6 to 1.2 mEq/L for maintenance therapy and 0.8 to 1.5 mEq/L for acute therapy. Levels above 1.5 mEq/L can cause mild to moderate toxicity, and levels above 2.0 mEq/L can cause severe toxicity. Levels above 3.0 mEq/L are considered a medical emergency.

A. Avoid the use of humidifiers. B. Position the cannula prongs curving upward in the nose. C. Clean the cannula prongs daily. D. Keep the oxygen tubing off the floor.

Correct Answer is C

Explanation

Clean the cannula prongs daily.

This is because the nasal cannula can become contaminated with bacteria and mucus, which can cause infection and irritation of the nasal mucosa. Cleaning the cannula prongs daily with soap and water can prevent these complications.

Choice A is wrong because humidifiers can help moisten the dry oxygen and prevent nasal dryness and bleeding. Humidifiers should be used for oxygen flow rates higher than 4 L/min.

Choice B is wrong because the cannula prongs should be positioned curving downward in the nose, not upward. This allows for better alignment with the natural direction of airflow and reduces the risk of dislodgement.

Choice D is wrong because keeping the oxygen tubing off the floor is not a specific action for nasal cannula use. It is a general safety measure to prevent tripping and contamination of the tubing.

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A nurse is caring for a client who is postpartum and asks the nurse why her newborn received a vitamin K injection. The nurse should explain that the injection is administered in order to prevent which of the following complications in the newborn?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client at a follow-up visit who has been taking lithium therapy for bipolar disorder. Which of the following findings should indicate to the nurse that the client is experiencing lithium toxicity?

Correct Answer is D

Explanation

A nurse is caring for a client who is receiving oxygen via nasal cannula at 4 L/min. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse at a long-term care facility is caring for a client who has AIDS. The client accidentally spills the contents of their urinal on the floor. After cleaning up the spill with soap and water, the nurse should apply a solution of water and which of the following disinfectants to the floor?

A nurse is contributing to the plan of care for a newly-admitted client who has schizophrenia and a history of aggressive behavior. Which of the following interventions should the nurse include in the initial plan?

A nurse is caring for a client who is at 10 weeks of gestation and reports nausea and vomiting on most days. Which of the following recommendations should the nurse make?

A nurse is reinforcing teaching with a client who requires a bladder-training program for urinary incontinence. Which of the following instructions should the nurse include in the teaching?

A nurse is reinforcing teaching with a newly licensed nurse about incident reports. The nurse should identify that which of the following situations requires the completion of an incident report?

A nurse is preparing a room for a client who has a tracheostomy tube. Which of following supplies should the nurse place in the room?

A nurse is reinforcing teaching with a newly licensed nurse about delegating tasks to assistive personnel (AP). Which of the following task-specific information should the nurse identify as a contraindication to delegating a task to an AP?

A nurse is preparing to give change-of-shift report to the oncoming nurse. Which of the following information should the nurse include?

A nurse is caring for a client who is postpartum and asks the nurse why her newborn received a vitamin K injection.
The nurse should explain that the injection is administered in order to prevent which of the following complications in the newborn?