Nokea
A mother wants to switch her 9 month-old infant from an iron-fortified formula to whole milk because of the expense. Upon further assessment, the nurse finds that the baby eats table foods well, but drinks less milk than before. What is the best advice by the nurse?
- A. Change the baby to whole milk
- B. Add chocolate syrup to the bottle
- C. Continue with the present formula
- D. Offer fruit juice frequently
Correct Answer: C
Rationale: Continue with the present formula. Switching to whole milk before 12 months can lead to allergies and lactose intolerance.
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A client one day after a thoracotomy.
Nursing actions on the care plan include: turn, cough, and deep breathe q2h. The nurse understands that the purpose of this nursing action is to
- A. promote ventilation and prevent respiratory acidosis.
- B. increase oxygenation and removal of secretions.
- C. increase pH and facilitate balance of bicarbonate.
- D. prevent respiratory alkalosis by increasing oxygenation.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-primary purpose of this nursing measure is to improve and/or maintain good gas exchange, especially removal of carbon dioxide in order to prevent respiratory acidosis (2) answer choice #1 is better in that it refers to ventilation rather than oxygenation (3) increasing the pH is not desirable (4) respiratory alkalosis is not prevented by this nursing measure
The mother of a 3-year-old hospitalized with lead poisoning asks the nurse to explain the treatment for her daughter. The nurse's explanation is based on the knowledge that lead poisoning is treated with:
- A. Gastric lavage
- B. Chelating agents
- C. Antiemetics
- D. Activated charcoal
Correct Answer: B
Rationale: Chelating agents , like succimer, bind lead for excretion. Gastric lavage and charcoal are ineffective for systemic lead. Antiemetics treat symptoms, not the cause.
Because a client has Guillain-Barré syndrome, the nurse would expect which of the following in the client's history?
- A. Recent upper respiratory infection
- B. A tick bite a few days ago
- C. A mosquito bite a week ago
- D. A strep throat infection two weeks ago
Correct Answer: A
Rationale: Guillain-Barré syndrome is often preceded by a viral upper respiratory infection, triggering an autoimmune response, unlike tick bites, mosquito bites, or strep throat.
An adult is hospitalized for heart failure. Hydrochlorothiazide and digoxin are prescribed. What laboratory test(s) should the nurse monitor because the client is taking these medications?
- A. CBC and differential
- B. Serum creatinine and BUN
- C. Cardiac enzymes
- D. Serum electrolytes
Correct Answer: D
Rationale: Hydrochlorothiazide and digoxin can cause electrolyte imbalances (e.g., hypokalemia), increasing digoxin toxicity risk, necessitating serum electrolyte monitoring.
The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who is receiving ipratropium (Atrovent) via inhaler. Which of the following client statements would be of GREATest concern to the nurse?
- A. I use my inhaler four times a day.
- B. I have a dry mouth.
- C. I feel dizzy sometimes.
- D. I rinse my mouth after using the inhaler.
Correct Answer: C
Rationale: Dizziness may indicate systemic absorption or hypoxia, a serious concern in COPD requiring evaluation. Options A, B, and D are less concerning: four times daily is standard, dry mouth is a common side effect, and rinsing is appropriate.