Nokea
A nurse is providing teaching to a group of parents of newborns who are planning to formula feed. Which of the following statements by a parent indicates a need for further teaching?
- A. "I will give formula to my baby at room temperature."
- B. "I will ensure my baby's feeds last 10 to 15 minutes."
- C. "I will burp my baby halfway through each feeding."
- D. "I will watch for signs my baby is full and stop the feeding."
Correct Answer: B
Rationale: The correct answer is, "I will ensure my baby's feeds last 10 to 15 minutes." This statement indicates a need for further teaching because it suggests a strict time limit for feedings, which may not be appropriate for a newborn. Newborns should be allowed to feed as long as they want, typically around 20-30 minutes per breast if breastfeeding, or on-demand with formula. Choices A, C, and D demonstrate proper feeding practices such as feeding at room temperature, burping halfway through each feeding, and watching for signs of fullness to stop the feeding, which are all appropriate responses by a parent of a formula-fed newborn.
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A nurse is teaching a client who needs to increase their daily fluid intake. Which of the following foods has the highest percentage of water by weight?
- A. Yogurt
- B. Milk
- C. Lettuce
- D. Honey
Correct Answer: C
Rationale: The correct answer is Lettuce. Lettuce has the highest percentage of water by weight among the options provided, making it an excellent choice to increase fluid intake. Yogurt and milk have some water content but are not as high in water percentage as lettuce. Honey, on the other hand, contains very little water and is not a good choice for increasing fluid intake.
A client is experiencing sleep disturbances and desires to decrease caffeine intake. Which of the following beverages should the nurse recommend?
- A. Lemon-lime soda
- B. Brewed iced tea
- C. Diet cola
- D. Chocolate milk
Correct Answer: B
Rationale: The nurse should recommend brewed iced tea as it generally contains less caffeine compared to other choices. Lemon-lime soda, diet cola, and chocolate milk all contain caffeine, which can contribute to sleep disturbances. Lemon-lime soda and diet cola are carbonated beverages that typically contain caffeine unless specified as caffeine-free. Chocolate milk also contains caffeine due to the cocoa content. Therefore, brewed iced tea is the most suitable choice to reduce caffeine intake and improve sleep quality.
A nurse is caring for a client who is to receive a mechanically altered diet. Which of the following client food choices necessitates intervention by the nurse?
- A. Scrambled eggs
- B. Cottage cheese
- C. Piece of wheat toast
- D. Sliced banana
Correct Answer: D
Rationale: The correct answer is 'Sliced banana.' A mechanically altered diet is designed for clients who have difficulty chewing or swallowing. Sliced bananas, due to their texture and potential choking hazard for clients with swallowing difficulties, would necessitate intervention by the nurse. Scrambled eggs, cottage cheese, and a piece of wheat toast are softer and safer options for clients on a mechanically altered diet, making them appropriate choices.
A nurse is providing discharge teaching for a client who has acute pancreatitis and has a prescription for fat-soluble vitamin supplements. The nurse should instruct the client to take a supplement for which of the following?
- A. Vitamin A
- B. Vitamin B1
- C. Vitamin C
- D. Vitamin B12
Correct Answer: A
Rationale: In acute pancreatitis, malabsorption of fat-soluble vitamins can occur due to pancreatic enzyme insufficiency. Vitamin A is a fat-soluble vitamin that may need supplementation in this case. Vitamin B1 (thiamine), Vitamin C, and Vitamin B12 are water-soluble vitamins and are not typically affected by pancreatic enzyme insufficiency in acute pancreatitis. Therefore, the correct supplement for the client with acute pancreatitis is Vitamin A.
A nurse is caring for a client who has cancer and is receiving total parenteral nutrition (TPN). Which of the following lab values indicates the treatment is effective?
- A. Hct 43%
- B. WBC 8,000/uL
- C. Albumin 4.2 g/dL
- D. Calcium 9.4 mg/dL
Correct Answer: C
Rationale: The correct answer is Albumin 4.2 g/dL. Albumin is a protein produced by the liver and is a key indicator of nutritional status. In a client receiving total parenteral nutrition (TPN), an increase in albumin level indicates that the treatment is effective in providing adequate nutrition support. Hct (hematocrit), WBC (white blood cell count), and calcium levels are not direct indicators of the effectiveness of TPN in this context.