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A child is prescribed ferrous sulfate. Which of the following instructions should the nurse include?
- A. Take with meals
- B. Take at bedtime
- C. Take with a glass of milk
- D. Take with a glass of orange juice
Correct Answer: D
Rationale: The correct answer is to take ferrous sulfate with a glass of orange juice. Vitamin C, found in orange juice, enhances iron absorption. Taking iron with milk (choice C) is not recommended as it reduces iron absorption. Taking it with meals (choice A) can hinder its absorption due to other food components. Taking it at bedtime (choice B) doesn't affect absorption but might cause gastrointestinal upset in some individuals.
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A nurse has been caring for a female client who has bruises on her arms that she explains are a result of physical abuse by her husband. The client states, "I don't know how much longer I can take this, but I'm afraid he'll really hurt me if I leave." Which of the following is an appropriate nursing intervention?
- A. Offer to speak to the client's husband regarding his abusive behavior
- B. Help the client to recognize signs of escalation in abusive behavior
- C. Assist the client in identifying personal behaviors that trigger abuse
- D. Assist the client in reporting the abusive behavior to authorities
Correct Answer: D
Rationale: Assisting the client in reporting the abuse is a critical step in ensuring her safety and initiating legal action to protect her from further harm. Option A is inappropriate as it may escalate the situation and put the client at further risk. Option B focuses on the client recognizing signs of abuse, which is not as urgent as reporting it to authorities. Option C places the responsibility on the client for triggering the abuse, which is victim-blaming and not helpful in this context.
A charge nurse is evaluating the time management skills of a newly licensed nurse. The charge nurse should intervene when the newly licensed nurse does which of the following?
- A. Re-evaluates priorities halfway through the shift
- B. Delegates changing a sterile dressing to a licensed practical nurse
- C. Groups activities for the same client
- D. Works on several tasks simultaneously
Correct Answer: D
Rationale: The correct answer is D. Working on several tasks simultaneously may lead to errors due to divided attention and lack of focus. It is important for nurses to prioritize tasks and complete them one at a time to ensure thoroughness and accuracy. Choices A, B, and C are appropriate time management strategies. Re-evaluating priorities, delegating tasks appropriately, and grouping activities for the same client can help improve efficiency and quality of care.
A nurse is planning discharge teaching for cord care for the parent of a newborn. Which instructions would you include in the teaching?
- A. Contact provider if the cord turns black
- B. Clean the base of the cord with hydrogen peroxide daily
- C. Keep the cord dry until it falls off
- D. The cord stump will fall off in ten days
Correct Answer: C
Rationale: The correct instruction to include in the teaching for cord care is to keep the cord dry until it falls off naturally. This helps prevent infection, as the cord typically falls off in 10-14 days, not within five days. Instructing the parent to contact the provider if the cord turns black (Choice A) is important to monitor for signs of infection. Cleaning the base of the cord with hydrogen peroxide daily (Choice B) is not recommended as it can delay healing. Stating that the cord stump will fall off in ten days (Choice D) provides a more accurate timeframe compared to the initial estimation of five days.
A client who is having suicidal thoughts tells the nurse, "It just doesn't seem worth it anymore. Why not end my misery?" Which of the following responses by the nurse is appropriate?
- A. Why do you think your life is not worth it anymore?
- B. Do you have a plan to end your life?
- C. I need to know what you mean by misery
- D. You can trust me and tell me what you're thinking
Correct Answer: B
Rationale: The appropriate response by the nurse is to ask about the client's plan to end their life. This question helps to assess the severity of the client's suicidal ideation and the immediacy of the risk, allowing the nurse to determine the appropriate level of intervention. Choices A, C, and D do not directly address the immediate risk assessment needed in this situation.
A nurse is assessing a client who has diabetes insipidus and is receiving desmopressin. Which of the following should the nurse monitor?
- A. Fasting blood glucose
- B. Carbohydrate intake
- C. Hematocrit
- D. Weight
Correct Answer: D
Rationale: The correct answer is D: Weight. Desmopressin can cause fluid retention, so monitoring the client's weight is crucial to detect signs of water intoxication or overhydration, which can occur with the medication. Monitoring fasting blood glucose (choice A) is not directly related to desmopressin use in diabetes insipidus. Carbohydrate intake (choice B) is important for diabetes management but is not specifically relevant to monitoring desmopressin therapy. Hematocrit (choice C) is not typically influenced by desmopressin use in diabetes insipidus.