Nokea
A client with congestive heart failure is newly admitted to home health care. The nurse discovers that the client has not been following the prescribed diet. What would be the most appropriate nursing action?
- A. Discharge the client from home health care because of noncompliance
- B. Notify the provider of the client's failure to follow prescribed diet
- C. Discuss diet with the client to learn the reasons for not following the diet
- D. Make a referral to Meals-on-Wheels
Correct Answer: C
Rationale: Discuss diet with the client to learn the reasons for not following the diet. When new problems are identified, it is important for the nurse to collect accurate assessment data. Before reporting findings to the provider, it is best to have a complete understanding of the client's behavior and feelings as a basis for future teaching and intervention.
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A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse? A client with
- A. a Dopamine drip IV with vital signs monitored every 5 minutes
- B. a myocardial infarction that is free from pain and dysrhythmias
- C. a tracheotomy of 24 hours in some respiratory distress
- D. a pacemaker inserted this morning with intermittent capture
Correct Answer: B
Rationale: This client is the most stable with minimal risk of complications or instability. The nurse can utilize basic nursing skills to care for this client, making it suitable for a nurse from another unit.
When teaching a 10 year-old child about their impending heart surgery, which form of explanation meets the developmental needs of this age child?
- A. Provide a verbal explanation just prior to the surgery
- B. Provide the child with a booklet to read about the surgery
- C. Introduce the child to another child who had heart surgery 3 days ago
- D. Explain the surgery using a model of the heart
Correct Answer: D
Rationale: Explain the surgery using a model of the heart. According to Piaget, the school age child is in the concrete operations stage of cognitive development. Using a model to explain the surgery meets the child’s developmental needs for concrete and visual learning.
A mother that has never breast-fed a child before is having trouble getting the baby to latch on to the breast. The baby has lost 3% of its birth weight within the first 2 days of life. The best statement is:
- A. The baby will eventually take to the breast.
- B. I can fix up a bottle if you want to try that.
- C. A small amount of weight loss in the first few days is normal.
- D. I can get the charge nurse to come and talk to you about breast-feeding.
Correct Answer: C
Rationale: 5-10% of birth weight loss following birth is normal for the first few days of life, and this response reassures the mother while allowing further discussion about breastfeeding challenges.
A nurse who is assigned to the emergency department needs to understand that gastric lavage is a priority in which situation?
- A. An infant who has been identified as suffering from botulism
- B. A toddler who has eaten a number of ibuprofen tablets
- C. A preschooler who has swallowed powdered plant food
- D. A school aged child who has taken a handful of vitamins
Correct Answer: A
Rationale: Botulinum toxin is a neurotoxin that causes muscular paralysis. Gastric lavage is a priority to remove the toxin from the stomach before it is absorbed.
The nurse is discussing with the parents of the full-term newborn the infant's transportation in a vehicle. Which information should the nurse provide? Select all that apply.
- A. The infant should be restrained in a car seat located in the backseat facing the rear of the car.
- B. The infant should be restrained in a car seat located in the backseat facing the front of the car.
- C. An infant car seat may be designed only for infants; if so, obtain another one when the infant reaches the weight limit for that model.
- D. Some states and provinces in the United States and Canada have mandated the use of infant and child restraints.
- E. A car seat should have a certification label stating that it complies with federal motor vehicle safety standards.
Correct Answer: A,C,E
Rationale: A: Rear-facing car seats in the backseat are safest. C: Infant-only car seats have weight limits requiring replacement. E: Certification ensures safety compliance. B is incorrect as forward-facing is unsafe for infants.