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A nurse is providing teaching about Iron deficiency anemia to the parents of a 14-month-old. Which of the following should the nurse recommend as a method of preventing iron deficiency anemia?
- A. Avoid a diet consisting of primarily milk.
- B. Include whole grains and legumes in the diet.
- C. Administer fat-soluble vitamins daily.
- D. Limit intake of high-protein foods.
Correct Answer: A
Rationale: Milk especially cow's milk is low in iron and can inhibit iron absorption. Excessive milk consumption can also lead to iron deficiency anemia by displacing iron-rich foods from the diet and potentially causing gastrointestinal bleeding in infants.
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A nurse is caring for a client who is postoperative immediately following a tonsillectomy. Which of the following snacks should the nurse offer the client?
- A. Lime ice pop
- B. Cranberry juice
- C. Ice cream
- D. Hot tea
Correct Answer: A
Rationale: A lime ice pop is a good option because it is cold soothing and less likely to irritate the throat or cause bleeding. The cold temperature can help reduce swelling and provide comfort.
A nurse is collecting data from a 5-month-old infant who has increased intracranial pressure (ICP) resulting from hydrocephalus. Which of the following manifestations should the nurse expect?
- A. Low-pitched cry
- B. Positive Babinski reflex
- C. Insomnia
- D. Bulging fontanel
Correct Answer: D
Rationale: A bulging fontanel is a key sign of increased ICP in infants. It occurs due to pressure within the skull causing the soft spot on the head to protrude.
A nurse is caring for a preschooler who has epiglottitis from a streptococcal infection. Which of the following actions should the nurse take?
- A. Attempt to obtain a throat culture.
- B. Use a tongue depressor to observe the back of the throat.
- C. Apply humidified oxygen via a mask.
- D. Initiate airborne precautions.
Correct Answer: C
Rationale: This helps to keep the airways moist and can provide some relief and improve oxygenation.
A nurse on a pediatric unit is receiving a report from an assistive personnel (AP). Which of the following clients should the nurse plan to visit first?
- A. A 4-year-old preschooler who has status asthmaticus and a pulse oximetry of 95%
- B. A 1-year-old infant who has roseola and a temperature of 39°C (102.2°F)
- C. A 7-year-old child who has diabetes insipidus and a urine specific gravity of 1.002
- D. A 10-year-old child who has sickle cell anemia and a pain rating of 6 on a 0 to 10 scale
Correct Answer: C
Rationale: A urine specific gravity of 1.002 indicates very dilute urine
A nurse is reinforcing teaching about preventing disease transmission with the parents of a child who has a streptococcal infection. Which of the following instructions should the nurse include?
- A. I'll give him acetaminophen for the pain.
- B. I'll discard his toothbrush and buy another.
- C. I'll continue to encourage him to drink lots of fluids.
- D. I'll take his temperature every 4 hours.
Correct Answer: B
Rationale: Replacing the toothbrush after starting antibiotics helps to reduce the risk of reinfection.