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 is the nurse's best interpretation of this?
- A. Resuscitation is likely to be needed.
- B. Adjustment to extrauterine life is adequate.
- C. Additional scoring in 5 more minutes is needed.
- D. Maternal sedation or analgesia contributed to the low score.
Correct Answer: B
Rationale: The nurse's best interpretation is that the adjustment to extrauterine life is adequate. This can be determined by the Apgar score, which assesses a newborn's well-being shortly after birth. A score of 7-10 indicates that the newborn is adjusting well to life outside the womb, while a score of 4-6 may indicate some difficulties that may require intervention. In this case, the nurse's interpretation suggests that the newborn is doing well in adapting to the new environment.
A client is admitted to the ICU, which laboratory result must be reported immediately to the physician?
- A. Hematocrit 48%
- B. paCO2 38 mm Hg
- C. platelets 18,000
- D. WBC count 8000
Correct Answer: C
Rationale: A platelet count of 18,000 is significantly low, indicating a condition known as thrombocytopenia, which can lead to a risk of bleeding. In a critical care setting like the ICU, low platelet counts need to be addressed urgently to prevent serious complications such as hemorrhage. This result must be reported immediately to the physician so that appropriate interventions, such as transfusion of platelets, can be initiated promptly to manage the patient's condition effectively. Hematocrit, paCO2, and WBC count may also be important parameters to monitor in an ICU patient, but the critically low platelet count poses the most immediate threat to the patient's well-being and requires urgent attention.
A patient has cloudy penile discharge. For which additional symptoms of urethritis should the nurse assess?
- A. Throat or rectal infection
- B. Chancres or vesicles on the genitals
- C. Painful and frequent urination
- D. Oliguria and flank pain
Correct Answer: C
Rationale: Cloudy penile discharge is a common symptom of urethritis, which is inflammation of the urethra usually caused by an infection, such as a sexually transmitted infection (STI) like gonorrhea or chlamydia. Painful and frequent urination are also classic symptoms of urethritis. Painful urination, or dysuria, may occur due to the irritation and inflammation of the urethra. Frequency of urination can be a result of the body's response to the infection or inflammation. Therefore, assessing for these additional symptoms helps in confirming the diagnosis of urethritis and determining the appropriate treatment for the patient.
In which of the ff clients will an MRI scan be contraindicated?
- A. Overweight clients
- B. Clients with metal implants in their body
- C. Clients over the age of 60
- D. Clients with brain tumor CARING FOR CLIENTS WITH CENTRAL AND PERIPHERAL NERVOUS SYSTEM DISORDERS
Correct Answer: B
Rationale: An MRI scan uses strong magnetic fields and radio waves to create detailed images of the body's internal structures. Clients with metal implants in their body, such as pacemakers, artificial joints, or other metallic objects, may experience potential risks and complications during an MRI scan. The strong magnetic field can interact with the metal in the body, causing movement, heating, or potential damage to the surrounding tissues. Hence, it is contraindicated to perform an MRI scan on clients with metal implants to avoid harm and ensure their safety.
In assisting a physician to perform a thoracentesis to Mr. Sy, how should the nurse postion a patient with pleural effusion of the left lung?
- A. supine with the left arm extended over the head
- B. sitting at the side of the bed with both arms resting on alocked overbed table
- C. high fowler's with both arms resting on pillows
- D. semi-fowlers with both arms resting on pillows
Correct Answer: B
Rationale: In performing a thoracentesis for a patient with pleural effusion of the left lung, the patient should be positioned sitting at the side of the bed with both arms resting on an overbed table. This position allows for better access to the left lung area and helps the patient maintain a comfortable and stable position during the procedure. Sitting position also helps to expand the intercostal spaces, making it easier for the physician to access the pleural fluid. Additionally, having both arms resting on an overbed table helps the patient remain still and reduce the risk of injury during the procedure. Therefore, this position is the most suitable for performing a thoracentesis for a patient with pleural effusion of the left lung.