The nurse is assessing a 2-day-old infant with a diagnosis of ventricular septal defect (VSD). Which finding should the nurse report immediately to the health care provider?

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Question 1 of 5

The nurse is assessing a 2-day-old infant with a diagnosis of ventricular septal defect (VSD). Which finding should the nurse report immediately to the health care provider?

Correct Answer: D

Rationale: Sweating during feeding needs immediate reporting in VSD. It indicates heart failure from shunt overload, per pathophysiology, requiring urgent care. Murmur is typical, weight gain minor, and HR 160 normal. D signals decompensation, making it critical.

Question 2 of 5

A fire breaks out in a trash can in the hallway of a medical unit. Which action should the nurse take first?

Correct Answer: A

Rationale: Pulling the nearest fire alarm is first in a hallway fire. It alerts staff and initiates response (RACE: Rescue, Alarm, Contain, Extinguish), per safety protocol. Extinguishing , evacuating , or closing doors follow. A ensures rapid help, making it priority.

Question 3 of 5

A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visit the nurse observes the client smacking her lips alternately with grinding her teeth. The nurse recognizes this assessment finding as what?

Correct Answer: D

Rationale: Tardive dyskinesia is indicated by lip smacking and teeth grinding in a client on chlorpromazine, a long-term antipsychotic side effect, per psychiatric nursing. Dystonia involves muscle spasms, akathisia is restlessness, and bradykinesia is slowed movement. D requires reporting, potentially adjusting therapy.

Question 4 of 5

The nurse is providing instructions for a client with pneumonia. What is the most important information to convey to the client?

Correct Answer: D

Rationale: Complete all of the antibiotic even if your findings decrease' is most important. It prevents resistance and relapse in pneumonia, per infectious disease guidelines. Rest , X-ray , and temperature matter but completing antibiotics ensures cure, making it the priority instruction.

Question 5 of 5

The nurse is talking by telephone with a parent of a 4 year-old child who has chickenpox. Which of the following demonstrates appropriate teaching by the nurse?

Correct Answer: C

Rationale: Papules, vesicles, and crusts will be present at one time' is correct for chickenpox, per infectious disease teaching. Aspirin risks Reye's syndrome, cortisone isn't standard, and contagion persists post-eruption. C educates accurately on progression.

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