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Which of the ff dietary recommendations should a nurse give to a client taking diuretics?
- A. Include potassium rich foods
- B. Avoid fruit and fruit juices
- C. Include protein rich foods
- D. Avoid dairy products
Correct Answer: A
Rationale: Diuretics are medications that help the body get rid of excess sodium and water through increased urine output. One common side effect of diuretics is the loss of potassium from the body. Therefore, it is important for clients taking diuretics to include potassium-rich foods in their diet to help maintain a healthy potassium level. Some examples of potassium-rich foods include bananas, oranges, potatoes, spinach, avocados, and tomatoes. By including these foods in their diet, clients taking diuretics can help prevent potassium deficiency and maintain overall health.
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The nurse is presenting an in-service session on assessing gestational age in newborns. Which information should be included?
- A. The newborn's length and weight are the most accurate indicators of gestational age.
- B. The newborn's Apgar score and the mother's estimated date of confinement (EDC) are combined to determine gestational age.
- C. The newborn's posture at rest and arm recoil are two physical signs used to determine gestational age.
- D. The newborn's chest circumference compared to the head circumference is the determinant for gestational age.
Correct Answer: C
Rationale: The newborn's posture at rest and arm recoil are two physical signs used to determine gestational age. Assessment of posture at rest involves observing the newborn's flexed or extended posture when lying flat on their back. Premature infants tend to have more flexed postures due to their immature muscular tone. Arm recoil refers to the ability of the newborn to return their extended arm flexes to the flexed position. This reflex is typically present in more mature infants. These physical signs, along with other factors such as skin texture, breast development, and ear formation, are used by healthcare providers to estimate the gestational age of newborns. While length, weight, and head circumference are also important measurements, the posture at rest and arm recoil are specifically used in determining gestational age.
Which is an important nursing action related to the use of tape and/or adhesives on preterm newborns?
- A. Avoid using tape and adhesives until skin is more mature.
- B. Use solvents to remove tape and adhesives instead of pulling on skin.
- C. Remove adhesives with warm water or mineral oil.
- D. Use scissors carefully to remove tape instead of pulling tape off.
Correct Answer: A
Rationale: An important nursing action related to the use of tape and/or adhesives on preterm newborns is to avoid using tape and adhesives until the skin is more mature. Preterm newborns have delicate and fragile skin that is more prone to damage and injury. Using tape and adhesives on immature skin can increase the risk of skin tears, irritations, and damage. It is recommended to wait until the skin matures and becomes less delicate before using tape or adhesives on preterm newborns to prevent skin-related complications.
During chemotherapy for lymphocytic leukemia, a client develops abdominal pain, fever, and "horse barn" smelling diarrhea. It would be most important for the nurse to advise the physician to order:
- A. Enzyme-linked immunosuppressant assay
- B. Stool for Clostridium difficile test
- C. Flat palate X-ray of the abdomen
- D. Electrolyte panel and hemogram
Correct Answer: B
Rationale: The client's symptoms of abdominal pain, fever, and "horse barn" smelling diarrhea are concerning for Clostridium difficile infection, especially in the setting of receiving chemotherapy which can weaken the immune system. Clostridium difficile is a bacteria that can cause severe diarrhea and inflammation of the colon. Testing for Clostridium difficile in the stool is crucial for diagnosing the infection and guiding appropriate treatment. Therefore, advising the physician to order a stool test for Clostridium difficile would be the most important in this scenario to confirm the diagnosis and initiate appropriate management.
Which interventions should the nurse implement when caring for a family of a sudden infant death syndrome (SIDS) infant? (Select all that apply.)
- A. Allow parents to say goodbye to their infant.
- B. Once parents leave the hospital, no further follow-up is required.
- C. Arrange for someone to take the parents home from the hospital.
- D. Avoid requesting an autopsy of the deceased infant.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which of the following tests is most effective in diagnosing hemophilia?
- A. Bleeding time
- B. Complete blood count (CBC)
- C. Partial thromboplastin time (PTT)
- D. Platelet count
Correct Answer: C
Rationale: Partial thromboplastin time (PTT) is the most effective test in diagnosing hemophilia. Hemophilia is a genetic disorder that results in prolonged clotting times due to deficiencies in specific clotting factors, such as factor VIII (hemophilia A) or factor IX (hemophilia B). PTT is a screening test that evaluates the intrinsic pathway of coagulation and helps identify deficiencies in clotting factors. In patients with hemophilia, PTT is typically prolonged due to the reduced activity of the deficient clotting factor. Therefore, measuring PTT can aid in the diagnosis of hemophilia by assessing the clotting function and identifying specific clotting factor deficiencies. Other tests like bleeding time, CBC, and platelet count are important in evaluating overall bleeding tendencies, but they are not as specific for diagnosing hemophilia as the PTT test.