Nokea
A mother who is breast-feeding and has known food sensitivities is asking the nurse what foods she should avoid in her diet. The nurse should advise her to avoid which foods? Select all that apply.
- A. Fish.
- B. Soy.
- C. Peanuts.
- D. Beef.
- E. Lamb.
Correct Answer: C
Rationale: Common food allergens like peanuts can pass through breast milk and cause reactions in sensitive infants. Fish, soy, beef, and lamb are less commonly associated with allergic reactions in breast-fed infants unless specific sensitivities are known.
You may also like to solve these questions
The nurse is assessing a client's disposable closed chest drainage system at the beginning of the shift and notes continuous bubbling in the water-seal chamber. What should the nurse determine is the possible cause of the bubbling?
- A. The system is intact.
- B. A pneumothorax is resolving.
- C. The suction to the system is shut off.
- D. There is an air leak somewhere in the system.
Correct Answer: D
Rationale: Continuous bubbling in the water-seal chamber through both inspiration and expiration indicates that air is leaking into the system. A resolving pneumothorax would show intermittent bubbling in the water-seal chamber with respiration. Shutting the suction off to the system stops bubbling in the suction control chamber, but does not affect the water-seal chamber.
The nurse is assessing a client with a diagnosis of polycythemia vera. Which clinical manifestation should the nurse expect to note in this client?
- A. Pallor
- B. Hypertension
- C. A low hematocrit level
- D. Pale mucous membranes
Correct Answer: B
Rationale: Polycythemia vera is a myeloproliferative disease that causes increased blood viscosity and blood volume. Manifestations of polycythemia vera include a ruddy complexion, dusky red mucosa, hypertension, dizziness, headache, and a sense of fullness in the head. Signs of heart failure may also be present. The hematocrit level is usually greater than 54% in men and 49% in women.
The nurse is caring for a client with a chest tube. Which observation indicates a potential complication?
- A. Continuous bubbling in the water seal chamber
- B. Tidaling in the water seal chamber
- C. Drainage of 50 mL/hour
- D. Secured dressings around the tube site
Correct Answer: A
Rationale: Continuous bubbling in the water seal chamber suggests an air leak, a potential complication requiring immediate investigation.
The nurse is assessing a newborn 12 hours after birth. Which of the following findings should be reported to the physician?
- A. Heart rate of 120 beats per minute.
- B. Respiratory rate of 40 breaths per minute.
- C. Acrocyanosis.
- D. Capillary refill of 5 seconds.
Correct Answer: D
Rationale: Capillary refill of 5 seconds indicates poor perfusion in a newborn, requiring physician notification.
The nurse is preparing to care for a client who has undergone esophagogastroduodenoscopy (EGD). After checking the vital signs, what should be the nurse's next priority?
- A. Monitor for sharp epigastric pain.
- B. Give warm gargles for sore throat.
- C. Check for a return of the gag reflex.
- D. Monitor for complaints of heartburn.
Correct Answer: C
Rationale: The nurse places highest priority on assessing for the return of the gag reflex, which is part of maintaining the client's airway. The nurse should also monitor the client for sharp pain (may indicate a potential complication) and heartburn. The client would receive warm gargles, but this cannot be done until the gag reflex has returned.