When planning the care for a SGA newborn, which action would the nurse determine as a priority?
A) Preventing hypoglycemia with early feedings
B) Observing for respiratory distress syndrome
C) Promoting bonding between the parents and the newborn
D) Monitoring vital signs every 2 hours
A
Response:
With the loss of the placenta at birth, the newborn must now assume control of glucose homeostasis. This is achieved by early oral intermittent feedings. Observing for respiratory distress, promoting bonding, and monitoring vital signs, although important, are not the priority for this newborn.
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The nurse is caring for a patient who is a victim of interpersonal violence (IPV). What is the nurse's first priority?
1. Assist the patient to devise a safety or escape plan. 2. Encourage the patient to take charge of the situation. 3. Make it clear to the patient that the partner needs to see a therapist. 4. Offer to contact outpatient services if the patient promises not to return home after discharge.
A nurse teaches an older adult about the antidepressant medication recently prescribed. Which of the following should the nurse include in the teaching? (Select all that apply.)
A) Antidepressants can interact with alcohol and over-the-counter medications. B) Depression is uncommon in the older adult population. C) Expect adverse effects of the medicine; stop medication if they occur. D) Don't expect immediate improvement; a fair trial may take up to 12 weeks. E) The medication is to be taken only as needed.
The nursing student observed behaviors during clinical rotation
Which behavior reflects the ethical behavior described by the National Federation of Licensed Practical Nurses (NFLPN) and the National Association for Practical Nurse Education and Service (NAPNES)? A) A nursing assistant (NA) wears gloves while cleansing the client's perineum, and then goes into the hall and, after looking both ways, picks up additional linens off the cart using gloved hands. B) A licensed practical/vocational nurse administered the wrong dosage of a medication and assesses the client for harm, reports and records the incident, and reviews proper drug administration. C) A registered nurse (RN) behind a pulled curtain is performing a sterile procedure, but drops a sterile item on the floor, picks it up, and uses it during the procedure. D) An unlicensed assistive personnel (UAP) enters into a client in airborne isolation without the proper protective attire, and then the UAP looks both ways in the hall and enters another client's room without first washing her hands.
During the health history a young male client asks the nurse why his scrotum rises and relaxes. The nurse would incorporate knowledge of which of the following when responding to this client?
A) When the temperature is warm, the scrotum rises. B) The cremasteric reflex controls the rise and relaxation of the scrotum. C) When the scrotum relaxes, it has many rugae. D) If the temperature is colder, the scrotum relaxes.