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A nurse is reinforcing teaching with the parent of a toddler about appropriate snacks. Which of the following foods should the nurse include in the teaching?
- A. Sliced bananas
- B. Raw celery
- C. Peanut butter
- D. Marshmallows
Correct Answer: A
Rationale: The correct answer is A: Sliced bananas. Sliced bananas are a healthy and safe snack option for toddlers as they provide essential nutrients and are easy to chew. Bananas are a good source of potassium and fiber. Choice B, raw celery, may pose a choking hazard for toddlers due to its stringy texture. Choice C, peanut butter, can also be a choking hazard and may not be suitable for all toddlers due to potential allergies. Choice D, marshmallows, are high in sugar and low in nutrients, making them an unhealthy choice for toddler snacks.
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A nurse is caring for a new mother who is breastfeeding her term newborn. The newborn weighed 3.4 kg (7.5 lb) at birth and weighs 3.3 kg (7.3 lb) on the second day of life. The mother expresses concern about the weight loss and asks the nurse about the amount of her breast milk. Which of the following responses by the nurse is appropriate?
- A. Why don't you switch to formula to ensure your baby is eating enough?
- B. It is common for new mothers to worry that they are not producing enough milk for their baby.
- C. A healthy newborn can lose 6% of his birth weight before starting to gain weight.
- D. Your newborn will need to remain in the hospital so his weight can be monitored.
Correct Answer: C
Rationale: The correct answer is C. A healthy newborn can lose up to 6% of their birth weight within the first few days of life, which is considered normal. This weight loss is usually due to fluid shifts and initial adjustments. Choices A, B, and D are incorrect. Choice A is inappropriate as switching to formula is not necessary at this point. Choice B, while acknowledging the mother's concerns, does not provide factual information about newborn weight loss. Choice D is unnecessary and may cause unnecessary stress to the mother and newborn since monitoring weight loss at home is sufficient unless there are other concerns.
After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is
- A. Abdominal x-ray
- B. Auscultation
- C. Flushing tube with saline
- D. Aspiration for gastric contents
Correct Answer: D
Rationale: After the insertion of an enteral feeding tube, the most accurate method for verifying its placement is by aspirating gastric contents. This method ensures that the tube is correctly positioned in the stomach. Abdominal x-ray can provide additional confirmation but is not as immediate or practical. Auscultation and flushing the tube with saline are not as reliable as aspirating gastric contents for verifying proper placement of an enteral feeding tube.
Which of these clients with associated lab reports is a priority for the nurse to report to the public health department within the next 24 hours?
- A. An infant with a positive stool culture for Shigella
- B. An elderly factory worker with a positive lab report for acid-fast bacillus smear
- C. A young adult commercial pilot with a positive histopathological examination for Pneumocystis carinii from an induced sputum
- D. A middle-aged nurse with a history of varicella-zoster virus and crops of vesicles on an erythematous base appearing on the skin
Correct Answer: B
Rationale: The correct answer is B because a positive acid-fast bacillus smear in an elderly factory worker suggests tuberculosis, a serious communicable disease that must be reported promptly to the public health department to prevent its spread. Choice A is incorrect as Shigella is an important pathogen, but it does not require immediate public health reporting. Choice C is incorrect because Pneumocystis carinii is an opportunistic pathogen and does not require urgent public health reporting. Choice D is incorrect as varicella-zoster virus causes chickenpox and shingles, both of which are not reportable diseases to the public health department.
The nurse is providing discharge teaching to a client with hypertension. Which of these statements made by the client indicates an understanding of the teaching?
- A. I will limit my intake of high-sodium foods.
- B. I will take my medications as prescribed by my healthcare provider.
- C. I will monitor my blood pressure regularly and keep a record to show my healthcare provider.
- D. I will limit my intake of high-fat foods.
Correct Answer: A
Rationale: The correct answer is A because limiting high-sodium foods is essential in managing hypertension and preventing complications. High sodium intake can lead to increased blood pressure levels. Choice B is important too, but solely relying on medications without lifestyle modifications may not be as effective in controlling hypertension. Choice C is also crucial for monitoring progress, but without dietary changes, blood pressure control may be challenging. Choice D, limiting high-fat foods, is beneficial for overall health but is not as directly related to managing hypertension as limiting high-sodium foods.
Which bed position is preferred for use with a client in an extended care facility on a falls risk prevention protocol?
- A. All 4 side rails up, wheels locked, bed closest to door
- B. Lower side rails up, bed facing the doorway
- C. Knees bent, head slightly elevated, bed in the lowest position
- D. Bed in the lowest position, wheels locked, place bed against the wall
Correct Answer: D
Rationale: The correct answer is D. Placing the bed in the lowest position, ensuring wheels are locked, and positioning it against the wall is the preferred bed position for a client in an extended care facility on a falls risk prevention protocol. This setup helps minimize the risk of falls by providing a stable and secure environment. Choices A, B, and C do not address key factors such as having the bed in the lowest position and placing it against the wall, which are crucial in preventing falls in such a setting.