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Questions 158

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Question 1 of 5

Which newborn assessment is considered an abnormal finding that requires immediate attention?

Correct Answer: C

Rationale: Jitteriness and shaking in a newborn may indicate hypoglycemia seizures or neurological issues requiring immediate attention. Cyanosis of hands and feet (acrocyanosis) three umbilical vessels and harlequin sign are normal or benign findings.

Question 2 of 5

A client is admitted with suspected Hodgkin's lymphoma. The diagnosis is confirmed by the:

Correct Answer: B

Rationale: Hodgkin's lymphoma is diagnosed by the presence of Reed-Sternberg cells in lymph node biopsy, a hallmark of the disease.

Question 3 of 5

The client is receiving total parenteral nutrition (TPN). Which assessment finding requires immediate action?

Correct Answer: A

Rationale: A blood glucose of 200 mg/dL indicates hyperglycemia, a common TPN complication requiring immediate action to adjust infusion or administer insulin. Weight gain, low-grade fever, and dry lips are less urgent.

Question 4 of 5

A nurse is performing a vaginal exam on a client in active labor. An important landmark to assess during labor and delivery are the ischial spines because:

Correct Answer: A

Rationale: The ischial spines mark the narrowest diameter of the pelvis, critical for assessing fetal descent during labor.

Question 5 of 5

Which of the following medications requires close observation for bronchospasm in the client with chronic obstructive pulmonary disease or asthma?

Correct Answer: D

Rationale: Verapamil has the respiratory side effect of nasal or chest congestion, dyspnea, shortness of breath (SO
B), and wheezing. Amrinone has the effect of increased contractility and dilation of the vascular smooth muscle. It has no noted respiratory side effects. Epinephrine has the effect of bronchodilation through stimulation. Propranolol, esmolol, and labetalol are -blocking agents, which can increase airway resistance and cause bronchospasms.

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