Nokea
During the client interview for a developmentally normal 18-month-old, the parent expresses concern about the small amount of food the child consumes. What is the nurse's priority intervention?
- A. Check the child for parasitic infections
- B. Consult a pediatric nutritionist for suspected eating disorder
- C. Notify the health care provider
- D. Reinforce teaching about the toddler's nutritional needs
Correct Answer: D
Rationale: Toddlers often eat small amounts due to slower growth rates and picky eating. Educating parents about normal toddler nutrition addresses concerns and promotes appropriate feeding practices.
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An adult is receiving nasal oxygen at 6 L/min. The client asks the nurse why the oxygen is humidified. What should the nurse include when responding to the client?
- A. Humidifying oxygen helps to prevent fire.
- B. Humidity increases the concentration of oxygen.
- C. Humidity helps to keep the nasal passages from drying out.
- D. Humidity reduces the growth of organisms in the tubing.
Correct Answer: C
Rationale: Humidification prevents nasal mucosal drying and discomfort at higher oxygen flow rates like 6 L/min, not fire prevention, concentration increase, or bacterial reduction.
The physician has ordered O2 at 3 liters/minute for a client with emphysema. Which device will deliver the most precise level of oxygen prescribed for the client?
- A. Nasal cannula
- B. Partial rebreather mask
- C. Simple face mask
- D. Venturi mask
Correct Answer: D
Rationale: The Venturi mask will deliver the most precise level of oxygen for the client with COPD. Answer A is incorrect, because the client may lose oxygen through an open mouth. Answers B and C are incorrect, because they are not used to deliver oxygen to the client with COPD.
The nurse is reinforcing teaching to a client with advanced chronic obstructive pulmonary disease who was prescribed oral theophylline. Which client statement indicates that additional teaching is required?
- A. I need to avoid caffeinated products.
- B. I need to get my blood drug levels checked periodically.
- C. I need to report anorexia and sleeplessness.
- D. I take cimetidine rather than omeprazole for heartburn.
Correct Answer: D
Rationale: Cimetidine inhibits theophylline metabolism, increasing toxicity risk. Omeprazole is safer, and this statement indicates a need for further teaching.
A client with acquired immunodeficiency syndrome has a T cell count of 180 . The medication frequently used for the client with T cell counts less than 200 is:
- A. Garamycin (gentamicin)
- B. Zovirax (acyclovir)
- C. Pentam (pentamidine)
- D. Immune globulin
Correct Answer: C
Rationale: Pentamidine is used for Pneumocystis prophylaxis in AIDS patients with T-cell counts <200. Gentamicin is an antibiotic, acyclovir treats herpes, and immune globulin is not specific.
The nurse is talking with a client who has urge incontinence and is receiving tolterodine. It would require immediate follow-up if the client reports
- A. straining to have a bowel movement
- B. going an entire workday without needing to urinate
- C. using over-the-counter artificial saliva products for dry mouth
- D. experiencing occasional dizziness in the morning and with position changes
Correct Answer: B
Rationale: Not urinating for an entire workday suggests urinary retention, a serious side effect of tolterodine, requiring immediate evaluation to prevent bladder damage.