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Patient data

Exhibits

The nurse is reviewing the orders for the infant of a diabetic mother to determine priorities

Which 6 orders take priority?

Transfer to NICU

Keep in warmer with bilirubin lights

Bolus of 2 ml/kg glucose 10% IV

Blood glucose level

Contact Respiratory Therapy for ABG and oxygen therapy

Feed immediately

Apply dextrose (sugar) gel inside the baby's cheek

Echocardiogram

Monitor for respiratory distress

Monitor temperature every 30 minutes

Answer and Explanation

Correct Answer : C,D,E,F,I,J

A. Transfer to NICU - While NICU care is important, immediate stabilization takes precedence.

B. Keep in warmer with bilirubin lights - This is important for thermoregulation and managing jaundice but is not the most immediate concern.

C. Bolus of 2 ml/kg glucose 10% IV - This is critical to address the hypoglycemia (blood glucose 35 mg/dl).

D. Blood glucose level - Monitoring is essential for ongoing assessment of hypoglycemia.

E. Contact Respiratory Therapy for ABG and oxygen therapy - Given the high respiratory rate and potential for respiratory distress, this is a priority.

F. Feed immediately - Feeding can help stabilize blood glucose levels.

G. Apply dextrose (sugar) gel inside the baby's cheek - This is an alternative to IV glucose but less immediate than a bolus.

H. Echocardiogram - Important for cardiac assessment but not an immediate priority.

I. Monitor for respiratory distress - Essential due to the high respiratory rate and risk of complications from maternal diabetes.

J. Monitor temperature every 30 minutes - Important for detecting hypothermia due to the low axillary temperature.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","D"]

Explanation

Salt substitutes can be used in moderation to help reduce sodium intake, which is beneficial for controlling blood pressure, a key aspect of managing coronary artery disease (CAD).

B. Eat more canned vegetables - Canned vegetables can be high in sodium, which is not recommended for clients with coronary artery disease as it can contribute to hypertension and further heart strain.

C. Include oatmeal for breakfast - This is a recommended practice as oatmeal is high in soluble fiber, which can help lower cholesterol levels.

D. Consume foods with saturated fats - Saturated fats can increase the level of bad cholesterol in the blood, contributing to the progression of coronary artery disease, thus not recommended.

E. Walk 30 minutes per day - This is a recommended practice as regular physical activity can help manage weight, lower cholesterol, and reduce blood pressure.

A. A sluggish blood return B. Cool sensation above the site C. Iced streak tracking the vein D. Circumferential skin irritation

Correct Answer is C

Explanation

A. A sluggish blood return: While a sluggish blood return may indicate potential issues with the IV line, it does not require immediate intervention unless accompanied by other signs of
complications.
B. Cool sensation above the site: Cool sensation above the site may indicate impaired circulation, but it is not as concerning as other findings requiring immediate intervention.
C. Iced streak tracking the vein: Correct! An iced streak tracking the vein suggests infiltration of IV fluids into the surrounding tissue, which can cause tissue damage and compromise the
effectiveness of the IV therapy. Immediate intervention is needed to prevent further complications.
D. Circumferential skin irritation: Circumferential skin irritation may indicate an allergic reaction or contact dermatitis, which requires attention but is not as urgent as an infiltration.

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Patient data Exhibits The nurse is reviewing the orders for the infant of a diabetic mother to determine priorities Which 6 orders take priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing lifestyle change education for a client to slow the progression of coronary artery disease. Which statements by the client should the nurse recognize as needing additional education? (Select at that apply)

Correct Answer is ["B","D"]

Explanation

The nurse is performing a routine assessment of an IV site for a client receiving both IV fluids and medications through the line. The client reports tenderness when the nurse touches the arm above the site. Which finding should the nurse expect which will require immediate intervention?

Correct Answer is C

Explanation

After receiving report, the nurse can most safely plan to assess which client last?

The nurse is providing lifestyle change education for a client to slow the progression of coronary artery disease. Which statement(s) made by the client should the nurse recognize as needing additional education? (Select all that apply.)

The nurse is caring for a group of clients with the help of a practical nurse (PN) Which nursing action(s) should the nurse assign to the PN? (Select all that apply)

A male client reports to the on-call clinic nurse that he took tadalafil 10 mg by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina but denies experiencing any current or recent chest pain. Which action should the nurse take?

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention(s) should the nurse implement? (Select all that apply.)

Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

Patient data

Exhibits

The nurse is reviewing the orders for the infant of a diabetic mother to determine priorities

Which 6 orders take priority?