Nokea
A nurse is planning a diet for a client with cystic fibrosis. Which of the following foods should not be included in the meal plan?
- A. Roasted chicken.
- B. Fried scallops.
- C. Milk shake.
- D. Egg omelet.
Correct Answer: B
Rationale: Fried scallops are high in fat and difficult to digest for a client with cystic fibrosis due to pancreatic insufficiency. A high-calorie, high-protein diet with moderate fat and pancreatic enzyme supplements is more appropriate.
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A 6-month-old child is discharged with a urinary stent after a procedure to repair a hypospadias. The nurse should tell the parents to:
- A. Avoid tub baths until the stent is removed.
- B. Measure output in the urinary bag.
- C. Avoid drinking fruit juice.
- D. Clean the tip of the penis 3 times a day with soap and water.
Correct Answer: A
Rationale: Avoiding tub baths prevents infection.
A child is admitted with a fracture of the femur and placed in skeletal traction. What should the nurse assess first?
- A. The pull of traction on the pin.
- B. The Ace bandage.
- C. The pin sites for signs of infection.
- D. The dressings for tightness.
Correct Answer: C
Rationale: Assessing pin sites for infection is the priority, as infection can lead to serious complications in skeletal traction.
The nurse reads the new medications orders for a 4-year-old child with nephrotic syndrome on the chart below: Orders D/C prednisolone 40 mg PO Daily Prednisolone 30 mg PO QOD The nurse should:
- A. Discontinue the prednisolone 40 mg and give the 30 mg dose today.
- B. Check the medication record first to see when the last dose of prednisolone was given.
- C. Start the 30 mg dose tomorrow.
- D. Contact the prescriber for clarification.
Correct Answer: D
Rationale: Clarification ensures correct dosing.
The parents of a child with a tracheoesophageal fistula express feelings of guilt about their baby's anomaly. Which of the following approaches by the nurse would best support the parents?
- A. Helping the parents accept their feelings as a normal reaction.
- B. Explaining that the parents did nothing to cause the newborn's defect.
- C. Encouraging the parents to concentrate on planning their baby's care.
- D. Urging the parents to visit their newborn as often as possible.
Correct Answer: A
Rationale: Acknowledging and normalizing the parents' guilt helps them process emotions and supports coping.
The physician orders an intravenous infusion of 5% dextrose in 0.25 normal saline to be infused at 2 mL/kg/hour in an infant who weighs 9 lb. How many milliliters per hour of the solution should the nurse infuse? Round to one decimal.
- A. 8.2 mL/hour
- B. 9.0 mL/hour
- C. 7.4 mL/hour
- D. 6.8 mL/hour
Correct Answer: A
Rationale: 9 lb = 4.08 kg; 2 mL/kg/hour × 4.08 kg = 8.16 mL/hour, rounded to 8.2.