Nokea
The nurse is talking with the parents of a 2 year old client about nutritional choices to promote growth and development. The family observes a strict vegan diet. Which of the following information should the nurse include? Select all that apply.
- A. Diets consisting of legumes as the only protein source are sufficient for growth.
- B. Green, leafy vegetables such as cabbage and broccoli are good sources of calcium.
- C. Preparing meals with vegetables and fruits will ensure sufficient vitamin B12 intake
- D. Sunlight, mushrooms, and fortified,subscribe plant based milks are good sources of vitamin D.
- E. Try to consume foods high in iron with foods high in vitamin C to increase iron absorption.
Correct Answer: B,D,E
Rationale: Leafy greens provide calcium, sunlight/mushrooms/fortified milks supply vitamin D, and vitamin C with iron enhances absorption. Legumes alone lack essential amino acids, and vegetables/fruits don't provide B12.
You may also like to solve these questions
The nurse is inserting an indwelling urinary catheter for a female client. Which of the following actions should the nurse take? Select all that apply.
- A. Use the nondominant hand to gently spread the labia folds
- B. Apply sterile gloves and place the drape under the client's buttocks.
- C. Insert and advance the catheter 2 in (5 cm) and then inflate the balloon
- D. Place the client on the back with the knees flexed and hips rotated externally.
- E. Cleanse the labia majora and labia minora before cleansing the urinary meatus
Correct Answer: A,B,D
Rationale: Spreading labia aids visualization. Sterile gloves and drape maintain sterility. Proper positioning facilitates insertion. Advancing only 2 inches is insufficient (should be 5-7 cm) before balloon inflation. Cleansing should start with the meatus , not labia.
A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome?
- A. Elevated blood glucose
- B. Elevated platelet count
- C. Elevated creatinine clearance
- D. Elevated hepatic enzymes
Correct Answer: D
Rationale: HELLP syndrome is characterized by hemolysis, elevated liver enzymes, and low platelets. Elevated hepatic enzymes are a key finding, so D is correct. Answers A, B, and C are not associated with HELLP syndrome.
The hospital nurse administers CPR to an adult male who is found unconscious, has no pulse, and is not breathing. What is the ratio of chest compressions to respirations for one-person rescue?
- A. Fifteen chest compressions to one breath
- B. Fifteen chest compressions to two breaths
- C. Thirty chest compressions to two breaths
- D. Thirty chest compressions to two breaths
Correct Answer: C
Rationale: Current CPR guidelines recommend 30 chest compressions to 2 breaths for one-person adult resuscitation, optimizing circulation and oxygenation.
The nurse is caring for a client who is receiving an intravenous infusion. Which finding would indicate that the client's IV has infiltrated?
- A. The client's arm is red and warm to the touch.
- B. The IV is running faster than the desired rate.
- C. The area around the infusion site is pale and cool to the touch.
- D. The client complains of severe pain up and down the arm.
Correct Answer: C
Rationale: Infiltration causes pale, cool skin around the IV site due to fluid leakage into tissues. Redness, fast infusion, or radiating pain suggest other issues.
Lab results indicate that the client's serum aminophylline level is 17 mcg/mL. The nurse recognizes that the aminophylline level is:
- A. Within therapeutic range
- B. Too high and should be reported
- C. Questionable and should be repeated
- D. Too low to be therapeutic
Correct Answer: A
Rationale: The therapeutic range for aminophylline is typically 10-20 mcg/mL. A level of 17 mcg/mL is within this range, so no action is needed. Answer B is incorrect as the level is not too high. Answer C is unnecessary as the level is clearly therapeutic. Answer D is incorrect as the level is not too low.