Nokea
A pre-term newborn is to be fed breast milk through nasogastric tube. Breast milk is preferred over formula for premature infants because it
- A. Contains less lactose
- B. Is higher in calories/ounce
- C. Provides antibodies
- D. Has less fatty acid
Correct Answer: C
Rationale: Provides antibodies. Breast milk offers maternal antibodies, enhancing immunity in preterm infants.
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The nurse is to open a sterile package. How should the nurse plan to open the first flap?
- A. Toward the nurse
- B. Away from the nurse
- C. To the right side
- D. To the left side
Correct Answer: B
Rationale: Opening the first flap away from the nurse maintains sterility by preventing hands from passing over the sterile field. Opening toward the nurse or to the sides risks contamination.
The nurse is teaching a client with a new diagnosis of type 1 diabetes about insulin glargine (Lantus). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this insulin at bedtime.
- B. I should not mix this insulin with other insulins.
- C. I should rotate injection sites.
- D. I should take this insulin when my blood sugar is high.
Correct Answer: D
Rationale: Taking insulin glargine when blood sugar is high is incorrect, as it is a long-acting basal insulin for steady control, not for acute hyperglycemia. Options A, B, and C are correct: bedtime dosing is standard, it should not be mixed, and rotation prevents lipodystrophy.
Which type of traction can the nurse expect to be used on a 7 year-old with a fractured femur and extensive skin damage?
- A. Ninety-ninety
- B. Buck's
- C. Bryant
- D. Russell
Correct Answer: A
Rationale: Ninety degree-ninety degree traction is used for fractures of the femur or tibia. A skeletal pin or wire is surgically placed through the distal part of the femur, while the lower part of the extremity is in a boot cast. Traction ropes and pulleys are applied.
A clinic nurse is taking a health history from a 34-year-old man newly diagnosed with Buerger's disease. The nurse would expect the client's complaints to include
- A. heart palpitations.
- B. dizziness when walking.
- C. blurred vision.
- D. digital sensitivity to cold.
Correct Answer: D
Rationale: vasculitis of blood vessels in upper and lower extremities
The nurse is teaching a parent about side effects of routine immunizations. Which of the following must be reported immediately?
- A. Irritability
- B. Slight edema at site
- C. Local tenderness
- D. Seizure activity
Correct Answer: D
Rationale: Seizure activity. Other reactions that should be reported include crying for >3 hours, temperature over 104.8 degrees Fahrenheit following DPT immunization, and tender, swollen, reddened areas.