Nokea
Mr. Aurelio diagnosed with heart failure, was prescribed with a 2 gm sodium diet. which of the following foods would nurse Norma instruct him to restrict?
- A. whole wheat bread
- B. canned tomato juice
- C. beef tenderloin strips
- D. apples
Correct Answer: B
Rationale: Canned tomato juice is often high in sodium content due to added salt during processing. Since Mr. Aurelio has been prescribed a 2 gm sodium diet, the nurse would instruct him to restrict foods high in sodium content, such as canned tomato juice. Whole wheat bread and apples are generally low in sodium, and beef tenderloin strips can be chosen in lean cuts and prepared without high sodium additives, making them more suitable for Mr. Aurelio's dietary restrictions.
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The nurse is aware that a common physiologic adaptation of children with tetralogy of Fallot is:
- A. Clubbing of fingers
- B. Slow, irregular respirations
- C. Subcutaneous hemorrhages
- D. Decreased red blood cell count
Correct Answer: A
Rationale: Clubbing of fingers is a common physiologic adaptation seen in children with tetralogy of Fallot. Clubbing is the result of chronic hypoxia and decreased oxygen levels in the blood. In children with tetralogy of Fallot, there is a structural defect in the heart that leads to mixing of oxygenated and deoxygenated blood in the heart and decreased oxygenation of the blood circulating to the body. This chronic hypoxia can cause clubbing of the fingers, where the tips of the fingers appear enlarged and the nails are rounded. Therefore, clubbing of fingers is a key sign to monitor in children with tetralogy of Fallot.
A client with acquired immunodeficiency syndrome (AIDS) is prescribed zidovudine (azidothymidine, AZT [retrovir]), 200mg PO every 4 hours. When teaching the client about this drug, the nurse should provide which instruction?
- A. "Take zidovudine with meals."
- B. "Take zidovudine on an empty stomach."
- C. "Take zidovudine every 4 hours around the clock."
- D. "Take over-the-counter(OTC) drugs to treat minor adverse reactions."
Correct Answer: C
Rationale: Zidovudine (AZT) is an antiretroviral drug used to treat HIV infection, including in AIDS patients. It is important to follow the prescribed dosing schedule to maintain consistent drug levels in the body and effectively control the HIV virus. Taking zidovudine every 4 hours around the clock helps ensure the medication's therapeutic effects are maintained throughout the day. It is crucial for the client to adhere to the prescribed dosing regimen to prevent the development of drug resistance and to achieve the best treatment outcomes. Taking zidovudine with meals, on an empty stomach, or taking over-the-counter drugs for minor adverse reactions are not the correct instructions related to the dosing schedule of zidovudine.
Which discharge instruction for a child with encopresis should the nurse question?
- A. Limit milk intake.
- B. Obtain a complete dietary log.
- C. Follow up with a child psychologist.
- D. Offer a diet high in protein.
Correct Answer: D
Rationale: A high-protein diet can worsen constipation; a high-fiber, balanced diet is preferable.
A 4-year-old weighing 15 kg produces 150 mL of urine in 10 hours. What should the nurse do?
- A. Notify the physician; urine output is too low.
- B. Encourage increased oral intake.
- C. Record the urine output in the chart.
- D. Administer IV fluids to rehydrate.
Correct Answer: C
Rationale: Expected urine output is 0.5-1 mL/kg/hr. For a 15-kg child over 10 hours, 75-150 mL is within normal limits.
Which immunoglobulin is specific to an allergic response?
- A. IgA
- B. IgE
- C. IgB
- D. IgG
Correct Answer: B
Rationale: IgE is the immunoglobulin specific to an allergic response. When an individual is exposed to an allergen, the immune system produces IgE antibodies that bind to mast cells and basophils. Upon re-exposure to the same allergen, these IgE antibodies trigger the release of histamine and other chemicals that cause allergic symptoms such as itching, swelling, and inflammation. IgE is not normally found in high concentrations in the bloodstream unless there is an allergic reaction occurring. Other immunoglobulins like IgA, IgG, and IgM are not specifically associated with allergic responses.