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A child with Leukemia is admitted for chemotherapy, and the nursing diagnosis, altered nutrition, less than body requirements related to anorexia, nausea, vomiting is identified. Which intervention should the nurse include in this child's plan of care?
- A. Allow the child to eat foods desired and tolerated
- B. Restrict foods brought from fast food restaurants
- C. Recommend eating the same foods as siblings eat at home
- D. Encourage a variety of large portions of food at every meal
Correct Answer: A
Rationale: Step 1: A child with Leukemia undergoing chemotherapy often experiences anorexia, nausea, and vomiting, leading to altered nutrition.
Step 2: Allowing the child to eat foods desired and tolerated promotes intake, ensuring adequate nutrition.
Step 3: Restricting foods (Choice B) can exacerbate the child's already limited intake and lead to nutritional deficiencies.
Step 4: Recommending the same foods as siblings (Choice C) may not address the specific needs of the child undergoing chemotherapy.
Step 5: Encouraging large portions of food (Choice D) may overwhelm the child and worsen their symptoms.
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A nurse is planning care for a client who is newly diagnosed with diabetes mellitus. Which instruction should the nurse include in this client¢â‚¬â„¢s teaching plan?
- A. Avoid all forms of sugar
- B. Check blood glucose levels once a week
- C. Rotate insulin injection sites
- D. Monitor urine ketone levels
Correct Answer: C
Rationale: The correct answer is C: Rotate insulin injection sites. This instruction is crucial to prevent lipohypertrophy, which can lead to inconsistent insulin absorption. By rotating injection sites, the client ensures proper insulin absorption and prevents complications. Checking blood glucose levels once a week (B) is not frequent enough for proper diabetes management. Avoiding all forms of sugar (A) is an outdated approach, as moderation is key. Monitoring urine ketone levels (D) is not as reliable as blood ketone testing for assessing diabetic ketoacidosis risk.
A 59-year-old male client is brought to the emergency room where he is assessed to have a Glasgow Coma Scale of 3. Based on this assessment, how should the nurse characterize the client's condition?
- A. The client is experiencing increased intracranial pressure
- B. He has a good prognosis for recovery
- C. This client is conscious, but is not oriented to time and place
- D. He is in a coma, and has a very poor prognosis
Correct Answer: D
Rationale: The correct answer is D because a Glasgow Coma Scale score of 3 indicates deep unconsciousness, which is classified as a coma. A GCS score of 3 signifies the lowest possible level of consciousness and is associated with a very poor prognosis due to the severity of neurological impairment. Choices A, B, and C are incorrect. Increased intracranial pressure may be present in comatose patients but is not solely indicated by a GCS score of 3. A good prognosis is unlikely with a GCS score of 3. Being unconscious with a GCS score of 3 does not equate to being conscious but disoriented as in choice C.
When caring for a laboring client whose contractions are occurring every 2-3 minutes, the nurse should document that the pump is infusing how many ml/hour?
- A. 5
- B. 10
- C. 15
- D. 20
Correct Answer: A
Rationale: The correct answer is A: 5 ml/hour. To calculate the infusion rate, you need to divide the total amount infused by the total time in hours. Given contractions every 2-3 minutes, which is equivalent to 20-30 contractions per hour, the pump should infuse at 5 ml/hour to ensure proper medication delivery. Choices B, C, and D are incorrect because they do not correspond to the frequency of contractions and may lead to under or overmedication.
A client is taught how to collect a 24-hour urine specimen. Which statement indicates understanding of the procedure?
- A. I should keep the urine specimen refrigerated.
- B. I need to start the collection in the morning after my first void.
- C. I will collect the urine for 24 hours and keep it on ice.
- D. I will start collecting the urine after discarding my first morning specimen.
Correct Answer: D
Rationale: The correct answer is D because discarding the first morning specimen ensures accurate collection starts. Choice A is incorrect because refrigeration is unnecessary for a 24-hour urine collection. Choice B is incorrect as the first void should be included. Choice C is incorrect as there's no need to keep the urine on ice.
A male client with diabetes mellitus takes Novolin 70/30 insulin before meals and azithromycin (Zithromax) PO daily, using medication he brought from home. When the nurse delivers his breakfast tray, the client tells the nurse that he took his insulin but forgot to take his daily dose of the Zithromax an hour before breakfast as instructed. What action should the nurse implement?
- A. Offer to obtain a new breakfast tray in an hour so the client can take the Zithromax
- B. Instruct the client to eat his breakfast and take the Zithromax two hours after eating
- C. Tell the client to skip that day's dose and resume taking the Zithromax the next day
- D. Provide a PRN dose of an antacid to take with the Zithromax right after breakfast
Correct Answer: B
Rationale: The correct answer is B: Instruct the client to eat his breakfast and take the Zithromax two hours after eating. This is the correct action because azithromycin is best absorbed when taken on an empty stomach, but if the client has already eaten, it is recommended to wait at least 2 hours after a meal before taking it. This ensures optimal absorption and effectiveness of the medication.
Choice A is incorrect because it does not address the timing issue of taking azithromycin on an empty stomach. Choice C is incorrect as skipping a dose of an antibiotic can lead to treatment failure. Choice D is incorrect as antacids can interfere with the absorption of azithromycin and should not be taken together.