Nokea
A newborn begins to cough, choke, and becomes cyanotic while feeding. What is the nurse's immediate action?
- A. Inform the physician.
- B. Have the mother stop feeding and observe.
- C. Remove the infant from the mother, place the infant in the crib for assessment, obtain oxygen saturation, and administer blow-by oxygen immediately.
- D. Continue feeding while monitoring.
Correct Answer: C
Rationale: Immediate removal from the feeding situation and rapid assessment with oxygen support is critical for airway safety.
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When doing a nutritional assessment on a Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. How should the nurse assess this diet?
- A. Indicates they live in poverty
- B. Is lacking in protein
- C. May provide sufficient amino acids
- D. Should be enriched with meat and milk
Correct Answer: C
Rationale: The nurse should assess that the diet of the Hispanic family, which consists mainly of vegetables, legumes, and starches, may provide sufficient amino acids. While this diet may lack animal sources of protein commonly found in meat and milk, plant-based foods like legumes and grains can complement each other to provide all essential amino acids necessary for protein synthesis in the body. This combination of foods essentially forms a complete protein source, supporting overall nutritional needs. It's important for the nurse to recognize the potential nutritional value in the diet and offer education on balanced meal planning to ensure adequate protein intake for the family. The assessment should focus on the overall nutrient adequacy and not solely on the presence of specific food items.
A 15-month-old toddler was able to do all the following EXCEPT
- A. walks alone
- B. makes tower of 3 cubes
- C. inserts raisin in a bottle
- D. responds to his/her name
Correct Answer: D
Rationale: Responding to name usually occurs earlier, around 6-9 months.
Basic principles of healthy sleep hygiene include all the following EXCEPT
- A. set routine time
- B. avoid stimulating activities as playing computer games
- C. spends meal out of your bedroom
- D. gives a heavy meal every day
Correct Answer: D
Rationale: Heavy meals before bedtime can disrupt sleep.
Pneumocystic pneumonia. Which anemias are described as microcytic, hypochromic anemia?
- A. Vitamin B12 and iron deficiency anemia
- B. Folic acid and iron deficiency anemia
- C. Iron deficiency anemia and thalassemia
- D. Sickle cell anemia and anemia if chronic disease
Correct Answer: C
Rationale: Microcytic, hypochromic anemia is characterized by small red blood cells with decreased hemoglobin content. Iron deficiency anemia and thalassemia are the two main types of anemia that present with these characteristics. Iron deficiency anemia is caused by a lack of iron in the body, which is essential for the production of hemoglobin. Thalassemia is a genetic disorder that results in decreased production of normal hemoglobin. Both conditions lead to small, pale red blood cells, fitting the description of microcytic, hypochromic anemia. Other choices such as Vitamin B12 deficiency anemia (choice A), folic acid deficiency anemia (choice B), sickle cell anemia (choice D), and anemia of chronic disease (choice D) typically present as normocytic or macrocytic anemias.
A client is undergoing peritoneal dialysis. Which of the ff is a major complication of the procedure that the nurse should monitor for?
- A. Internal hemorrhage
- B. Hydronephrosis
- C. Ecchymosis
- D. Peritonitis
Correct Answer: D
Rationale: Peritonitis is a major complication of peritoneal dialysis that the nurse should monitor for. Peritonitis is an infection of the peritoneum, the membrane that lines the abdominal cavity and covers the abdominal organs. It can occur when bacteria from the dialysis solution enter the peritoneal cavity. Symptoms of peritonitis may include abdominal pain, cloudy dialysis effluent, fever, and general signs of infection. Prompt recognition and treatment of peritonitis are crucial to prevent complications such as sepsis and peritoneal membrane damage. Regular monitoring and strict aseptic technique during peritoneal dialysis can help reduce the risk of peritonitis.