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Questions 227

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Extract:

The nurse doing a newborn assessment counts the infant's cord vessel.


Question 1 of 5

In a normal infant there are:

Correct Answer: C

Rationale: There are three vessels: one vein (carries oxygenated blood to the fetus) and two arteries (return deoxygenated blood to the placenta) in a normal umbilical cord.

Extract:

A new mother has some questions about PKU.


Question 2 of 5

Which of the following statements made by the nurse is correct regarding PKU?

Correct Answer: B

Rationale: The PKU test is performed shortly after birth to detect phenylalanine levels.

Extract:


Question 3 of 5

A nurse's neighbor complains of severe right flank pain. She explains that it began during the night, but she was able to take acetaminophen (Tylenol) and return to bed. When she awoke, the pain increased in intensity. How should the nurse intervene?

Correct Answer: C

Rationale: The nurse should advise the neighbor to seek medical attention. Explaining that she can't give medical advice might cause a delay in treatment. It's beyond the nurse's scope of practice to suggest that the neighbor might need surgery. Telling the neighbor she'll be fine might also delay treatment, and it isn't a professional response.

Question 4 of 5

A postoperative client is to be discharged today. She will need to change her dressing daily. Which statement she makes indicates that she understands the process?

Correct Answer: A

Rationale: Hand washing before and after dressing changes prevents infection, reflecting proper understanding.
Touching dressings, cleaning toward the incision, or improper disposal increase infection risk.

Extract:

John H is a 66-year-old man with a history of heavy smoking presented himself to the ER due to difficulty breathing of 2 years duration. Mr. H was also diagnosed with effusion of the right lung. He is now scheduled for chest tube insertion.


Question 5 of 5

Appropriate patient teaching when the chest tube is removed:

Correct Answer: A

Rationale: Holding a deep breath during removal prevents air entry into the pleural space.

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