A nurse is performing change of shift assessments for four clients. Which of the following findings should the nurse prioritize?

A client who has gastroenteritis and is lethargic and confused

A client who has cystic fibrosis, has a thick, productive cough, and reports thirst

A client who has sickle cell anemia and reports pain 15 minutes after receiving oral analgesic

A client who has diabetes mellitus and has a morning fasting capillary glucose of 185 mg/dL

Answer and Explanation

The Correct Answer is A

A. Gastroenteritis can lead to dehydration and electrolyte imbalances, which can cause lethargy and confusion. This indicates a potentially serious condition requiring immediate attention.

B. While cystic fibrosis requires management, the symptoms described (thick, productive cough and thirst) are not immediately life-threatening.

C. Sickle cell anemia pain is significant but may not require immediate intervention if the client has just received analgesia and is being monitored.

D. While a morning fasting capillary glucose of 185 mg/dL is elevated in a client with diabetes mellitus, it does not require immediate intervention unless accompanied by symptoms of hyperglycemia such as confusion or lethargy.

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Correct Answer is B

Explanation

A. "I should place a rolled blanket along each side of my baby's head in the car seat." - Incorrect. Placing rolled blankets on each side of the baby's head is not recommended as it can increase the risk of suffocation. Infants should be positioned in the car seat without any extra padding or blankets.

B. "I should place my baby's car seat rear-facing until 6 months of age." - Correct. Rear- facing car seats are recommended for infants until they reach at least 2 years of age or until they outgrow the weight and height limits specified by the car seat manufacturer. This position provides the best protection for the baby's head, neck, and spine in the event of a crash.

C. "I should put the car seat retainer clip at the level of my baby's belly button." - Incorrect.

The retainer clip should be positioned at armpit level to secure the harness straps properly.

D. "I should position my baby's car seat at a 90-degree angle in the car." - Incorrect. Car seats should be installed at the appropriate recline angle according to the manufacturer's

instructions, which may vary depending on the specific car seat model and the child's age and size.

A. Clothe the newborn in light cotton. B. Check the newborn's temperature every 8 hr. C. Administer 120 mL (4 oz) of water between feedings. D. Place the newborn 45 cm (18 in) from the light source.

Correct Answer is D

Explanation

- A. Clothing the newborn in light cotton is not recommended because it can block the light from reaching the skin, which is necessary for the treatment of hyperbilirubinemia through phototherapy.
- B. Checking the newborn's temperature every 8 hours is not frequent enough; during phototherapy, it is important to monitor the newborn's temperature more frequently to ensure they do not become too cold or too warm as a result of the therapy.
- C. Administering water between feedings is not recommended as it can interfere with the newborn's feeding schedule and nutrition; breast milk or formula provides adequate hydration unless otherwise indicated by a healthcare provider.
- D. Placing the newborn 45 cm (18 in) from the light source is the correct intervention. This distance allows for optimal exposure to the light while ensuring the safety and comfort of the newborn, as recommended in clinical guidelines for effective phototherapy.

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A nurse is performing change of shift assessments for four clients. Which of the following findings should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching about car seat safety to the parent of a term newborn. Which of the following statements by the parent indicates an understanding of the teaching?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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