Nokea
A nurse is planning care for a toddler who has burns over 50% total body surface area. Which of the following actions should the nurse include in the plan of care?
- A. Administer enteral feedings
- B. Limit intake of vitamin C
- C. Limit dietary protein
- D. Administer insulin prior to meals
Correct Answer: A
Rationale: Administering enteral feedings is crucial for ensuring adequate nutrition and supporting healing in toddlers with extensive burns. Burns over 50% total body surface area can lead to increased metabolic demands, making it essential to provide nutrition through enteral feedings to meet the child's needs for healing and recovery. Limiting intake of vitamin C or dietary protein would be detrimental in this scenario as the child requires increased amounts of nutrients to support healing. Administering insulin prior to meals is not indicated in this case as the priority is to provide adequate nutrition to promote healing.
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A patient is being cared for by a nurse who has stomatitis following radiation treatment. Which of the following is an appropriate intervention for the nurse to take?
- A. Serve foods without sauces or gravies
- B. Offer mouth rinses with normal saline and water
- C. Serve foods while still at a hot temperature
- D. Instruct the client to drink liquids without a straw
Correct Answer: B
Rationale: Offering mouth rinses with normal saline and water is an appropriate intervention for a nurse caring for a patient with stomatitis following radiation treatment. This intervention can help soothe and clean the mouth, promoting comfort and oral hygiene. Choice A is incorrect because serving foods without sauces or gravies does not directly address the client's stomatitis. Choice C is incorrect because serving hot foods can exacerbate discomfort in the client's mouth. Choice D is incorrect because using a straw can help in preventing further irritation in the client's mouth.
A nurse is preparing to administer a gavage feeding via a nasogastric tube to a preterm newborn who is receiving supplemental oxygen. Which of the following actions should the nurse take?
- A. Stabilize the tube with tape to the newborn's cheek.
- B. Remove supplemental oxygen during the feeding.
- C. Measure the stomach aspirate prior to the feeding.
- D. Place the newborn on their left side for 30 minutes after the feeding.
Correct Answer: C
Rationale: Measuring the stomach aspirate prior to the feeding is crucial to ensure the correct placement and function of the nasogastric tube. This step helps prevent complications such as aspiration or improper feeding. Choice A is incorrect as stabilizing the tube with tape to the newborn's cheek can cause discomfort and skin irritation. Choice B is incorrect because removing supplemental oxygen during the feeding may compromise the newborn's respiratory status. Choice D is incorrect because placing the newborn on their left side for 30 minutes after the feeding is not a standard practice and is unnecessary for administering gavage feeding.
A nurse is providing anticipatory guidance to a client who has Phenylketonuria (PKU) and is planning a pregnancy. Which of the following information should the nurse include in the discussion?
- A. Diet sodas should not be consumed more than two or three times a week.
- B. Serum bilirubin should be monitored once or twice a month during pregnancy.
- C. Breastfeeding will not prevent your baby from developing PKU.
- D. A low-protein diet should be followed for three months before conception.
Correct Answer: D
Rationale: A low-protein diet should be followed for three months before conception in individuals with PKU who are planning a pregnancy. This diet helps manage PKU by reducing phenylalanine levels, which is crucial for maternal and fetal health. Choices A, B, and C are incorrect. Choice A is not directly related to managing PKU, choice B focuses on a different aspect of care during pregnancy, and choice C is inaccurate as breastfeeding will not prevent a baby from developing PKU.
A nurse is planning care for a client who has ascites secondary to liver disease. Which of the following interventions should the nurse include in the plan of care?
- A. Reduce complex carbohydrates to 30% of total calories.
- B. Restrict protein intake to less than 0.8 g/kg/day.
- C. Decrease daily caloric intake by 20%.
- D. Limit sodium to 2000 mg or less per day.
Correct Answer: D
Rationale: The correct answer is to limit sodium to 2000 mg or less per day. Ascites, which is the abnormal accumulation of fluid in the abdominal cavity, is commonly associated with liver disease. Limiting sodium intake helps manage fluid retention by reducing the fluid accumulation in the abdomen. Choices A, B, and C are incorrect because reducing complex carbohydrates, restricting protein intake, or decreasing caloric intake are not the primary interventions for managing ascites in liver disease.
A nurse is providing teaching about food allergies to the parents of a toddler. Which of the following foods should the nurse identify as highest risk for allergies in toddlers?
- A. Eggs
- B. Milk
- C. Bananas
- D. Citrus fruits
Correct Answer: A
Rationale: The correct answer is A: Eggs. Eggs are one of the most common food allergens in toddlers and should be introduced carefully. Milk (choice B) is also a common allergen but is typically introduced earlier in a child's diet. Bananas (choice C) and citrus fruits (choice D) are less likely to cause allergic reactions compared to eggs.