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A nurse is caring for a 2-year-old toddler. Which of the following food choices should the nurse recommend to promote independence in eating?
- A. Banana slices
- B. Grapes
- C. Hot dog
- D. Popcorn
Correct Answer: A
Rationale: The correct answer is A: Banana slices. Toddlers at the age of 2 are developing their fine motor skills and independence. Banana slices are easy for toddlers to pick up and eat independently, promoting their self-feeding skills. Grapes pose a choking hazard due to their size and shape. Hot dogs are also a choking hazard as they can easily get stuck in a toddler's throat. Popcorn is a common choking hazard for young children due to its hard texture. Therefore, recommending banana slices will not only promote independence in eating but also ensure safety for the toddler.
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For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.
- A. Irrigate indwelling urinary catheter with 50 mL of normal saline:
- B. Administer enema to relieve constipation
- C. Maintain bed rest for 2 days postoperatively
- D. Place a blanket rob under the client's knees while in bed.
- E. Apply warm compresses to the incision site.
Correct Answer:
Rationale: Rationales provided within the question context.
A nurse is developing a care plan for a client who is in Buck's traction and is scheduled for surgery for a fractured femur of the right leg. Which of the following interventions should the nurse delegate to assistive personnel?
- A. Ask the client to describe her pain.
- B. Check the client's pedal pulse on the right leg
- C. Observe the position of the suspended weight
- D. Remind the client to use the incentive spirometer.
Correct Answer: D
Rationale: Correct Answer: D. Remind the client to use the incentive spirometer.
Rationale:
1. Incentive spirometer use is a task that can be safely delegated to assistive personnel.
2. It is a non-invasive procedure and does not require advanced nursing skills.
3. Using the incentive spirometer helps prevent respiratory complications post-surgery.
4. Assistive personnel can remind the client to use it regularly, promoting lung expansion and preventing atelectasis.
Summary of other choices:
A: Asking the client to describe pain requires nursing assessment skills.
B: Checking the client's pedal pulse requires nursing assessment skills.
C: Observing the position of the suspended weight requires nursing judgment to adjust if needed.
Which of the following statements by the client indicates an understanding of the teaching?
- A. I should not use my affected hand for 4 to 6 weeks.
- B. I will need to keep my hand elevated above my heart for several days.
- C. I should expect numbness and tingling in my hand.
- D. I can apply heat for the first 24 hours to minimize the pain in my hand.
Correct Answer: B
Rationale: Elevation reduces swelling postoperatively.
The nurse should expect a prescription for which of the following laboratory tests?
- A. Platelet count
- B. Potassium level
- C. Creatinine clearance
- D. Prealbumin
Correct Answer: A
Rationale: Petechiae and ecchymoses suggest thrombocytopenia warranting platelet count evaluation.
A nurse is providing discharge teaching about home care of a surgical incision to a client who speaks a different language from the nurse. The nurse is communicating with the client using an interpreter. Which of the following actions should the nurse take?
- A. Speak slowly when talking to the interpreter.
- B. Pause in the middle of sentences
- C. Speak directly to the client
- D. Use gestures to convey meaning
Correct Answer: C
Rationale: The correct answer is C: Speak directly to the client. This is important because even when using an interpreter, the nurse should maintain eye contact and address the client directly to establish trust and ensure the message is accurately conveyed. Speaking slowly (choice A) may be helpful, but it is not as crucial as direct communication. Pausing in the middle of sentences (choice B) could lead to confusion. Using gestures (choice D) may not always accurately convey the intended message. Therefore, speaking directly to the client is the most effective way to ensure clear communication and understanding.