Nokea
A two-day-old infant in the newborn nursery does not appear interested in taking formula from the mother or the nurse.
An appropriate nursing diagnosis is high risk for
- A. impaired swallowing.
- B. failure to thrive.
- C. fluid volume deficit.
- D. altered health maintenance.
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) no information about swallowing provided with question (2) this is a medical diagnosis not a nursing diagnosis (3) correct-may become dehydrated (4) not specific for problem described
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A client has been receiving lithium (Lithane) for the past two weeks for the treatment of bipolar illness. When planning client teaching, what is most important for the nurse to emphasize?
- A. Maintain a low sodium diet
- B. Take a diuretic with lithium and avoid excessive fluids
- C. Don't be overly concerned if feelings of depression occur
- D. Come in for evaluation of serum lithium levels regularly
Correct Answer: D
Rationale: Come in for evaluation of serum lithium levels regularly. Regular monitoring prevents toxicity, especially during conditions like hot weather that affect sodium levels.
A toddler admitted with an elevated blood lead level is to be treated with intramuscular (IM) injections of calcium disodium edetate (Calcium EDTA) and dimercaprol (BAL).
Which of the following nursing actions should have the highest priority?
- A. Keep a tongue blade at the bedside.
- B. Encourage the child to participate in play therapy.
- C. Apply cool soaks to the injection site.
- D. Rotate the injection sites.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) no longer used for seizures, but it is important to have seizure precautions and emergency respiratory equipment available (2) important to implement, but is not a priority (3) contains incorrect information (4) correct-highest priority is to prevent tissue damage and promote tissue absorption of the medicine, accomplished through rotation of the injection sites
The nurse is teaching a client with a new diagnosis of migraine headaches about sumatriptan (Imitrex). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication at the first sign of a headache.
- B. I should avoid driving after taking this medication.
- C. I should report chest pain to my doctor.
- D. I should take this medication every morning to prevent headaches.
Correct Answer: D
Rationale: Taking sumatriptan daily to prevent migraines is incorrect, as it is used to abort acute attacks, not for prophylaxis. Options A, B, and C are correct: early use maximizes efficacy, sedation may impair driving, and chest pain may indicate vasoconstriction.
Which of the following findings is consistent with a diagnosis of congestive heart failure?
- A. Jugular vein distention indicates increased fluid volume
- B. Carbon dioxide reading of 30
- C. Hemoglobin of 18
- D. Potassium level of 5.5
Correct Answer: A
Rationale: Jugular vein distention reflects increased fluid volume and right-sided heart failure, a hallmark of congestive heart failure. Other options are not specific to this condition.
A client is placed on cephalexin monohydrate (Keflex) prophylactically after surgery.
Which of the following foods should the nurse encourage?
- A. Bran cereals and fruits.
- B. Egg whites and lean meats.
- C. Yogurt and acidophilus milk.
- D. Fish and poultry meats.
Correct Answer: C
Rationale: Strategy: The topic of the question unstated. Read the answer choices for clues. (1) unnecessary to encourage (2) unnecessary to encourage (3) correct-these foods will help maintain normal inTest inal flora, which may be altered by the Keflex (4) unnecessary to encourage