Nokea
After teaching the parents of a toddler about appropriate snack foods for their child, the nurse judges that the instructions about not giving the child raisins for snacks are effective when the father states should be following?
- A. Raisins are low in nutritional value
- B. Raisins are easy to choke on
- C. Raisins can increase tooth decay
- D. Raisins are hard to digest entirely
Correct Answer: B
Rationale: Raisins are a choking hazard for toddlers due to their size and texture, making this the correct reason to avoid them. Nutritional value, tooth decay, and digestion are less relevant concerns.
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Which of the following should the nurse identify as a priority nursing diagnosis for an infant with intussusception?
- A. Deficient fluid volume
- B. Impaired skin integrity
- C. Acute pain
- D. Impaired gas exchange
Correct Answer: C
Rationale: Acute pain is the priority nursing diagnosis for an infant with intussusception due to bowel obstruction causing severe abdominal pain. Fluid volume and gas exchange may be concerns but are secondary.
The nurse obtains a finger-stick glucose of 400 mg/dL (22.85 mmol/L) for a client who receives total parenteral nutrition (TPN). Which follow-up intervention should the nurse implement?
- A. Discontinue the current TPN infusion.
- B. Decrease the infusion rate of the TPN.
- C. Replace TPN with 5% dextrose solution.
- D. Confer with provider for glucose control.
Correct Answer: D
Rationale: A glucose level of 400 mg/dL indicates significant hyperglycemia, which is a potential complication of TPN due to its high dextrose content. The nurse should confer with the primary health care provider to obtain orders for glucose control, such as insulin administration, to manage the hyperglycemia safely. Discontinuing or altering the TPN infusion without provider orders is inappropriate, as TPN is a critical nutrition source, and abrupt changes could cause metabolic imbalances. Replacing TPN with 5% dextrose would not address the hyperglycemia and could exacerbate it.
During a home visit to a primiparous client 1 week postpartum who is bottle-feeding her neonate, the clientiant tells the nurse that her mother has suggested that she feed the neonate cereal so he will sleep through the night. Which of the following would be the nurse's best response?
- A. It is permissible to give the baby cereal if it is thinned with formula.'
- B. The time for starting cereal varies, so check with your pediatrician.'
- C. Formula is the food best digested by the baby until about 4 to 6 months of age.'
- D. If cereal is given too early in life, the undigested food can lead to a need for surgery.'
Correct Answer: C
Rationale: Formula is best for infants until 4-6 months, as early introduction of solids like cereal can cause digestive issues.
The nurse is teaching a client with gastroesophageal reflux disease (GERD) about lifestyle modifications. Which statement indicates understanding?
- A. I should eat large meals to avoid snacking.'
- B. I will sleep flat to relax my stomach.'
- C. I'll avoid lying down for 2 hours after eating.'
- D. I can drink orange juice with breakfast.'
Correct Answer: C
Rationale: Avoiding lying down for 2 hours after eating prevents acid reflux by keeping the stomach contents below the esophagus.
The nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following laboratory values should the nurse monitor closely?
- A. Serum potassium.
- B. Serum sodium.
- C. Blood urea nitrogen.
- D. Blood glucose.
Correct Answer: D
Rationale: TPN contains high glucose concentrations, requiring close monitoring of blood glucose to prevent hyperglycemia.