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Extract:

Laboratory reference ranges
Glucose (fasting)
Infant – Within 24 hours after birth
≥40 mg/dL (2.2 mmol/L)


Question 1 of 5

The nurse is caring for assigned newborns. Which of the following newborns should the nurse check first?

Correct Answer: D

Rationale: A glucose level of 38 mg/dL with jitteriness (
D) indicates hypoglycemia, a critical condition requiring immediate intervention. Crackles (
A), asymmetric Moro reflex (
B), and respiratory rate of 52 (
C) are less urgent.

Extract:


Question 2 of 5

A client has chronic obstructive pulmonary disease exacerbation. The pulse oximeter shows a saturation of 86% on room air. The nurse finds bilateral diminished lung sounds and low-pitched wheezing posteriorly, shallow respirations, respiratory rate of 32/min, and use of accessory muscles. What is the most appropriate oxygen delivery device for this client?

Correct Answer: D

Rationale: A Venturi mask (
D) delivers precise oxygen concentrations, ideal for COPD exacerbation to avoid hypercapnia. Nasal cannula (
A), non-rebreathing mask (
B), and Oxymizer (
C) are less precise.

Question 3 of 5

A 45-year-old client is in a rehabilitation unit receiving long-term care for injuries sustained in a motor vehicle accident. The client's spouse used to stay home but started working to replace the client's lost income. The nurse notices that the client has become withdrawn and increasingly frustrated by small inconveniences. Which statement is the most appropriate first response by the nurse?

Correct Answer: B

Rationale: Acknowledging observed behavior (
B) opens a therapeutic conversation and validates the client's feelings. Asking about the spouse's job (
A), assuming anger (
C), or suggesting a support group (
D) may not address the client's current emotional state.

Question 4 of 5

Which interventions does the nurse perform to promote normal rest and sleep patterns for a critically ill client? Select all that apply.

Correct Answer: A, C, D

Rationale: Dimming lights (
A), opening blinds in the morning (
C), and scheduling activities during the day (
D) promote circadian rhythms and rest. Leaving the TV on (
B) may disrupt sleep, and turning off alarms (E) compromises safety.

Question 5 of 5

The nurse is beginning nutritional counseling/teaching with a pregnant woman. What is the initial step in this interaction?

Correct Answer: D

Rationale: Assessment is always the first step in planning teaching for any client. A thorough and accurate history is essential for gathering the needed information.

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