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A parent is being taught by a nurse how to prevent sudden infant death syndrome (SIDS). Which statement by the parent indicates an understanding of how to place the infant in the crib at bedtime?
- A. Place the infant on their stomach to sleep.
- B. Place the infant on their side to sleep.
- C. Place the infant on their back to sleep.
- D. Allow the infant to sleep with a pacifier.
Correct Answer: C
Rationale: The correct answer is C: 'Place the infant on their back to sleep.' This statement indicates an understanding of the recommended sleep position to reduce the risk of SIDS. Placing infants on their back is the safest sleep position according to guidelines to prevent SIDS. Choices A and B are incorrect as placing the infant on their stomach or side increases the risk of SIDS. While allowing the infant to sleep with a pacifier can also reduce the risk of SIDS, the most crucial step is placing the infant on their back for sleep.
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A nurse is assessing a client who has cirrhosis. Which of the following findings should the nurse expect?
- A. Clay-colored stools.
- B. Hypertension.
- C. Stridor.
- D. Elevated temperature.
Correct Answer: A
Rationale: Clay-colored stools are a classic finding in a client with cirrhosis. Cirrhosis can lead to impaired bile flow, resulting in pale or clay-colored stools due to a lack of bilirubin in the stool. Hypertension, stridor, and elevated temperature are not typically associated with cirrhosis. Hypertension may occur in cirrhosis but is not a consistent finding, stridor is more commonly associated with upper airway obstruction, and elevated temperature may indicate an infection rather than a direct result of cirrhosis.
A client is receiving intermittent enteral tube feedings and is experiencing dumping syndrome. Which of the following actions should the nurse take?
- A. Administer a refrigerated feeding.
- B. Increase the amount of water used to flush the tubing.
- C. Decrease the rate of the client's feedings.
- D. Instruct the client to move onto their right side.
Correct Answer: C
Rationale: Dumping syndrome is a condition that occurs when food moves too quickly from the stomach into the small intestine. Symptoms can include abdominal cramping, diarrhea, and sweating. To manage dumping syndrome in a client receiving enteral tube feedings, the nurse should decrease the rate of the feedings. This intervention helps slow down the movement of food through the gastrointestinal tract, reducing the symptoms. Administering a refrigerated feeding (choice A) or increasing the amount of water used to flush the tubing (choice B) are not appropriate actions for addressing dumping syndrome. Instructing the client to move onto their right side (choice D) is not a relevant intervention for managing dumping syndrome in this scenario.
A nurse is caring for a client who has chronic kidney disease and reports nausea. The nurse should identify that this client is at risk for which of the following imbalances?
- A. Metabolic alkalosis
- B. Metabolic acidosis
- C. Respiratory alkalosis
- D. Respiratory acidosis
Correct Answer: B
Rationale: The correct answer is B: Metabolic acidosis. Clients with chronic kidney disease are at risk for metabolic acidosis because the kidneys are unable to effectively excrete acids, leading to an accumulation of acid in the body. This metabolic imbalance can result in symptoms like nausea. Choices A, C, and D are incorrect. Metabolic alkalosis is not typically associated with chronic kidney disease. Respiratory alkalosis is more commonly seen in conditions such as hyperventilation. Respiratory acidosis, on the other hand, is often linked to conditions affecting the lungs or respiratory system, not primarily kidney disease.
A client taking haloperidol is exhibiting extrapyramidal symptoms. Which intervention should the nurse anticipate?
- A. Increase the dose of haloperidol.
- B. Administer benztropine.
- C. Administer naloxone.
- D. Monitor blood pressure before administering the next dose.
Correct Answer: B
Rationale: The correct intervention for a client exhibiting extrapyramidal symptoms while taking haloperidol is to administer benztropine. Benztropine is an anticholinergic medication commonly used to manage extrapyramidal symptoms caused by antipsychotic medications like haloperidol. Increasing the dose of haloperidol (Choice A) would exacerbate the symptoms rather than alleviate them. Administering naloxone (Choice C) is not indicated for extrapyramidal symptoms. Monitoring blood pressure (Choice D) is important but not the primary intervention for managing extrapyramidal symptoms.
A nurse is assessing a client who has chronic obstructive pulmonary disease (COPD). Which of the following findings should the nurse expect?
- A. Increased oxygen saturation with exercise.
- B. Pursed-lip breathing with exertion.
- C. Productive cough with clear sputum.
- D. Clubbing of the fingers.
Correct Answer: C
Rationale: The correct answer is C: 'Productive cough with clear sputum.' Clients with COPD often have a chronic productive cough with thick, often purulent sputum. This sputum can be white, yellow, green, or clear. Choices A, B, and D are incorrect. Oxygen saturation may decrease with exertion in COPD due to impaired gas exchange. Pursed-lip breathing is used to control dyspnea, not directly related to increased saturation with exercise. Clubbing of the fingers is typically seen in conditions such as cyanotic heart disease or lung cancer.