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Before a cancer receiving total parenteral nutrition (TPN) resumes a normal diet, the nurse teaches him about dietary sources of minerals. Which foods are good sources of zinc?
- A. Fruits and yellow vegetables
- B. Fruits and green vegetables
- C. Yeast and legumes
- D. Whole grains and meats
Correct Answer: D
Rationale: Zinc is an essential mineral that plays a crucial role in immune function, wound healing, and overall growth and development. Good dietary sources of zinc include whole grains and meats. Whole grains such as wheat and rice contain moderate amounts of zinc, while meats such as beef, pork, and chicken are rich sources of this mineral. Including these foods in the diet can help ensure an adequate intake of zinc, especially for individuals who have increased nutritional needs like cancer patients receiving TPN.
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Wilma knew that James have an adequate respiratory condition if she notices that
- A. James' respiratory rate is 18
- B. James' Oxygen saturation is 91%
- C. There are frank blood suction from the tube
- D. There are moderate amount of tracheobronchial secretions
Correct Answer: A
Rationale: An adequate respiratory condition can be indicated by a normal respiratory rate. The normal adult respiratory rate typically ranges from 12 to 20 breaths per minute. In this case, if James' respiratory rate is 18, it falls within the normal range and would suggest that his respiratory condition is adequate. Oxygen saturation levels and the presence of blood suction or secretions are important factors to consider as well, but directly assessing the respiratory rate provides a more immediate indication of respiratory status.
To prevent infection in a patient with a subdural intracranial pressure monitoring system in place, the nurse should;
- A. Use aseptic technique for the insertion site.
- B. Use clean technique for cleansing connections and aseptic technique for the insertion site.
- C. Use sterile technique when cleansing the insertion site
- D. Close any leaks in the tubing with tape. SITUATION: Mr. Dela Isla, a client with early Dementia exhibits thought process disturbances.
Correct Answer: A
Rationale: To prevent infection in a patient with a subdural intracranial pressure monitoring system in place, the nurse should use aseptic technique for the insertion site. Aseptic technique involves maintaining a sterile field to prevent the introduction of microorganisms that could lead to infection. Using aseptic technique specifically for the insertion site helps reduce the risk of introducing pathogens into the patient's intracranial system, reducing the chances of infection. Additionally, maintaining a strict aseptic technique is crucial for preventing complications and ensuring patient safety when managing intracranial pressure monitoring systems.
A nurse is performing an otoscopic exam on a school-age child. Which direction should the nurse pull the pinna for this age of child?
- A. Up and back
- B. Down and back
- C. Straight back
- D. Straight up
Correct Answer: A
Rationale: When performing an otoscopic exam on a school-age child, the nurse should pull the pinna (outer ear) of the child in an upward and backward direction. This technique helps to straighten the ear canal, allowing for better visualization and easier insertion of the otoscope to examine the ear canal and eardrum. Pulling the pinna in the wrong direction could potentially cause discomfort to the child or obstruct the view of the ear canal. Therefore, pulling the pinna up and back is the correct direction for this age group.
A 9-mo-old infant is recently diagnosed with bilateral retinoblastoma; examination under anesthesia reveals bilateral multifocal involvement of the retina. An important next step in the management is
- A. radiotherapy of both eyes
- B. retinal examination of 1st degree relatives
- C. orbital ultrasonography
- D. bilateral enucleation
Correct Answer: B
Rationale: Retinal examination of first-degree relatives is crucial to identify hereditary forms of retinoblastoma.
The parent of a 2-week-old infant, exclusively breastfed, asks the nurse if fluoride supplements are needed. What is the nurse's best response?
- A. "She needs to begin taking them now."
- B. "They are not needed if you drink fluoridated water."
- C. "She may need to begin taking them at age 4 months."
- D. "She can have infant cereal mixed with fluoridated water instead of supplements."
Correct Answer: B
Rationale: The nurse's best response to the parent of a 2-week-old infant, exclusively breastfed, regarding the need for fluoride supplements is that they are not needed if the infant is already drinking fluoridated water. Fluoride supplements are typically recommended for infants who are not receiving enough fluoride through their water source. Breast milk itself does not contain a significant amount of fluoride, but if the family's water supply is fluoridated, the infant will likely receive an adequate amount of fluoride without the need for supplements. It is important for the parent to verify the fluoride content of their water supply with their local water utility to ensure the infant is receiving the appropriate amount of fluoride for dental health.