A nurse is obtaining the temperature of a newborn. Which of the following sites should the nurse use?

Tympanic

Oral

Axillary

Rectal

Answer and Explanation

The Correct Answer is C

A. Tympanic thermometers are not recommended for newborns because the ear canal is difficult to assess accurately in this age group.

B. Oral temperatures are not recommended for newborns due to the difficulty in ensuring accuracy.

C. The axillary site is the recommended method for obtaining a newborn's temperature. It is safe and non-invasive.

D. Rectal temperatures are accurate but are invasive and may cause discomfort or injury. It should only be used if other methods are not feasible.

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Correct Answer is C

Explanation

A. The number of sponges used during surgery is important but does not provide as much relevant information for postoperative care.

B. The intubation status is relevant to the immediate perioperative period, but the primary concern in hand-off is the current postoperative condition.

C. Estimated blood loss is an important clinical detail to convey during hand-off, as it may impact the client's recovery and need for monitoring.

D. The client’s position or professional role (e.g., being a board member) is not relevant to the care plan and should not be included in the hand-off report.

A. Administer flumazenil to the client. B. Monitor the client's IV site for thrombophlebitis. C. Initiate seizure precautions for the client. D. Evaluate the client for further suicidal behavior.

Correct Answer is A

Explanation

A. Flumazenil is the antidote for benzodiazepine overdose and should be administered to reverse the effects of diazepam.

B. Monitoring the IV site is important but not an immediate priority in this situation.

C. Seizure precautions are not the primary concern after benzodiazepine overdose.

D. Evaluating for suicidal behavior is important but comes after stabilizing the client.

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System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that would help but it has not.. I found the title to the car today, signed over to me.
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom. Client reports not wanting to eat anymore. Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says, "Why don't you just leave me? I am of no use."

A nurse is obtaining the temperature of a newborn. Which of the following sites should the nurse use?

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Naxlex Comprehensive Predictor Exams

A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report?

Correct Answer is C

Explanation

A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets 20 min ago. The client is lethargic and a respiratory rate of 10/min. After securing the client's airway and initiating an IV, which of the following actions should the nurse take next?

Correct Answer is A

Explanation

A nurse is assessing a child who has bacterial pneumonia. Which of the following manifestations should the nurse expect?

A nurse is teaching a client about a variety of stress management techniques. Which of the following instructions by the nurse is appropriate?

A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make?

A nurse is caring for a client. Exhibits Complete the following sentence by using the lists of options. The client is at risk of developing ____1__ due to the client ___2___.

A nurse is assessing the fontanels of an 8-month-old infant. Which of the following findings should the nurse recognize as an expected finding?

A nurse in the emergency department (ED) is caring for an older adult client. Exhibits Which of the following prescriptions from the provider should the nurse anticipate? Select all that apply.

A nurse is assessing a client who has histrionic personality disorder. Which of the following manifestations should the nurse expect?