Nokea
A nurse is reinforcing teaching with the mother of a 9-month-old infant regarding appropriate dietary choices. Which of the following observations by the nurse indicates a need for further teaching?
- A. The infant eats the same foods prepared for the rest of the family.
- B. The mother gives the infant finger foods, such as apple slices for a snack.
- C. The infant drinks 2 quarts of whole milk a day.
- D. The infant drinks from a cup with a cover.
Correct Answer: C
Rationale: The correct answer is C. Infants should not consume more than 24 ounces of milk a day as it can lead to iron deficiency anemia and other issues. Choices A and B demonstrate appropriate dietary choices for a 9-month-old, as they involve providing the infant with family foods and appropriate finger foods. Choice D is also appropriate as it shows the infant is transitioning to drinking from a cup.
You may also like to solve these questions
A nurse is reinforcing teaching with a client about dietary choices for celiac disease. Which of the following menu choices selected by the client indicates an understanding of the teaching?
- A. Hamburger on a wheat bun
- B. Baked chicken and potato chips
- C. Bacon, lettuce, and tomato sandwich on rye toast
- D. Beef and barley soup with crackers
Correct Answer: B
Rationale: The correct answer is B because baked chicken and potato chips are gluten-free options suitable for a client with celiac disease. Choice A, a hamburger on a wheat bun, contains gluten, which is harmful to individuals with celiac disease. Choice C, a bacon, lettuce, and tomato sandwich on rye toast, also contains gluten. Choice D, beef and barley soup with crackers, includes gluten from the barley and crackers, making it unsuitable for someone with celiac disease.
After surgery, a client has been taken off the ventilator and has a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client?
- A. Allow the client to melt ice chips in the mouth
- B. Provide mints to freshen the breath
- C. Perform frequent oral care with a tooth sponge
- D. Swab the mouth with glycerin swabs
Correct Answer: C
Rationale: Performing frequent oral care with a tooth sponge is the most appropriate nursing measure in this situation. It helps maintain oral hygiene, prevent dryness, and provide comfort for a client with an NG tube. Allowing the client to melt ice chips may not be suitable immediately post-surgery due to potential risks. Providing mints or swabbing the mouth with glycerin swabs may not address the need for proper oral care and hygiene, which is essential for a client with an NG tube.
A nurse is providing care to a 63-year-old client with pneumonia. Which intervention promotes the client's comfort?
- A. Increase oral fluid intake
- B. Encourage visits from family and friends
- C. Keep conversations short
- D. Monitor vital signs frequently
Correct Answer: C
Rationale: Keeping conversations short is the most appropriate intervention to promote comfort for a client with pneumonia. Pneumonia can be physically exhausting, and limiting the length of conversations helps conserve the client's energy. Encouraging visits from family and friends (Choice B) may be emotionally supportive but might not directly promote comfort in the context of conserving energy during recovery. Increasing oral fluid intake (Choice A) is important for hydration but may not directly address the client's comfort. Monitoring vital signs frequently (Choice D) is essential for assessing the client's condition but does not directly promote comfort.
A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure?
- A. Increased blood pressure
- B. Increased heart rate
- C. Loss of pulse in the extremity
- D. Decreased urine output
Correct Answer: C
Rationale: Loss of pulse in the extremity can indicate an arterial blockage, requiring immediate medical evaluation. Increased blood pressure and heart rate are common physiological responses after cardiac catheterization and may not necessarily indicate a complication. Decreased urine output is more indicative of renal function and may not be directly related to complications from the procedure.
A client is being maintained on heparin therapy for deep vein thrombosis. The nurse must closely monitor which of the following laboratory values?
- A. Bleeding time
- B. Platelet count
- C. Activated PTT
- D. Clotting time
Correct Answer: C
Rationale: Activated PTT is the correct lab value to monitor for clients on heparin therapy. Activated PTT (partial thromboplastin time) helps assess the effectiveness of heparin therapy by measuring the time it takes for blood to clot. Monitoring activated PTT ensures that the client is within the therapeutic range of heparin to prevent both clotting and bleeding complications. Bleeding time (Choice A) and platelet count (Choice B) are not specific indicators of heparin therapy effectiveness. Clotting time (Choice D) is not as sensitive as activated PTT in monitoring heparin therapy.