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Questions 227

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Extract:

After 1 minute after birth, the nurse notes that an infant is crying, has a heart rate of 140, has acrocyanosis, resists the suction catheter, and keeps arms extended.


Question 1 of 5

The nurse should assign this infant an Apgar score of:

Correct Answer: C

Rationale: Crying (2), HR 140 (2), acrocyanosis (1), resists suction (2), extended arms (1) yield an Apgar of 8.

Extract:


Question 2 of 5

An elderly diabetic who has been maintained on metformin (Glucophage) is scheduled for a cardiac catheterization. Which instruction should be given to the client?

Correct Answer: C

Rationale: Metformin can cause renal problems, and the contrast dye used in cardiac catheterization is nephrotoxic. The medication should be discontinued before the exam and replaced with insulin temporarily.

Question 3 of 5

Nurses caring for clients who have cancer and are taking opioids need to assess for all of the following except:

Correct Answer: D

Rationale: Addiction is not a primary concern in terminally ill clients receiving opioids for pain management.
Tolerance, constipation, and sedation are common side effects requiring assessment. Basic Care and Comfort

Question 4 of 5

A primigravida, 26 years old and 33 weeks gestation, is admitted to the hospital with painless vaginal bleeding. She reports that the bleeding, which started 2 hours ago, has lessened in amount. Which of the following measures should be included in the client's care?

Correct Answer: B

Rationale: Counting the number of pads used quantifies blood loss, aiding in the assessment of conditions like placenta previa, which causes painless bleeding.

Extract:

When a patient is unconscious, the nurse should expect the patient to be unable to:


Question 5 of 5

When a patient is unconscious, the nurse should expect the patient to be unable to:

Correct Answer: B

Rationale: Unconscious patients cannot control elimination due to loss of voluntary muscle control.

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