Nokea
A nurse is teaching a parent about administration of iron supplements to a 7-month-old infant. Which should the nurse include in the teaching session? (Select all that apply.)
- A. Administer the iron supplement with a dropper toward the side and to the back of the mouth
- B. Administer the iron supplement with feedings.
- C. Your infant's stools may look tarry green.
- D. Your infant may have some diarrhea initially.
Correct Answer: A
Rationale: Administer the iron supplement with a dropper toward the side and to the back of the mouth: This instruction helps ensure that the iron supplement bypasses the taste buds on the front of the tongue, which may reduce the likelihood of a strong taste causing rejection or spitting out by the infant.
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Which food should be avoided by the patient on a low-sodium diet?
- A. Apples
- B. Chicken
- C. Cheese
- D. Broccoli
Correct Answer: C
Rationale: Cheese is high in sodium and should be avoided by patients on a low-sodium diet. It is a common source of hidden sodium in many diets. Other high-sodium foods that should be limited or avoided include processed meats, canned soups, processed snacks, and condiments. Patients should focus on eating fresh fruits and vegetables, lean proteins like chicken (with no added salt), and whole grains to maintain a low-sodium diet.
The nurse would expect which of the following would be included in the plan of care/
- A. Have the client drink at least 8 glases of water in the first day
- B. Administer NaHCO3 IV as per physician's orders
- C. Continue sodium bicarbonate for nausea
- D. Monitor electrolytes for hypokalemia and hypocalcemia
Correct Answer: D
Rationale: Monitoring electrolytes for hypokalemia (low potassium levels) and hypocalcemia (low calcium levels) is essential in the plan of care for a client. These electrolyte imbalances can be common in cases of dehydration and vomiting, and they can lead to serious complications if not detected and managed promptly. Hypokalemia can cause cardiac arrhythmias and muscle weakness, while hypocalcemia can lead to neuromuscular irritability and seizures. By monitoring electrolyte levels, the nurse can identify any imbalances early and take necessary interventions to prevent adverse outcomes.
A nurse prepares to administer the medication in which muscle site?
- A. Deltoid
- B. Triceps
- C. Vastus lateralis
- D. Biceps
Correct Answer: C
Rationale: The nurse prepares to administer the medication in the vastus lateralis muscle site. This site is located on the thigh and is commonly used for intramuscular injections in infants, toddlers, and smaller children. It is preferred for its large and easily accessible muscle mass, making it suitable for injections. This muscle site is also less painful and has fewer major blood vessels and nerves, reducing the risk of complications during injection.
Which of the ff is a sign or symptom characteristic of the later stages of TB?
- A. Fatigue
- B. Anorexia
- C. Hemoptysis
- D. Weight loss
Correct Answer: C
Rationale: Hemoptysis, which refers to coughing up blood, is a sign characteristic of the later stages of tuberculosis (TB). This symptom occurs when there is significant damage to the lungs due to the progression of the disease. Hemoptysis in TB can indicate advanced disease and the presence of cavities in the lungs where blood vessels may become eroded. It is a serious symptom that often requires immediate medical attention. While fatigue, anorexia, and weight loss are common symptoms of TB, hemoptysis specifically points towards the later stages of the disease and severe lung involvement.
A 39-year old male client underwent Transurethral Resection of the Prostate (TURP) eight hours ago and asks the nurse, "Why is my urine in the bag clotting like blood?" The nurse's best interpretation of this finding is that:
- A. after the surgery, bleeding is normal
- B. it is common for blood clots to be irrigated from the bladder for a day or so
- C. the physician needs to be called as the patient is bleeding
- D. the client is tugging on the catheter causing irritation to the bladder mucosa
Correct Answer: A
Rationale: After undergoing Transurethral Resection of the Prostate (TURP), it is normal for a client's urine to contain blood and form clots initially. This is because the surgery involves removing prostate tissue, which can lead to bleeding. The presence of blood clots in the urine collection bag is expected within the first 24 hours post-op. It is necessary to monitor for excessive bleeding or signs of a clot blocking the catheter, but seeing blood clots is not alarming in the immediate post-operative period.