Nokea
Mrs. Baker was instructed by the nurse on foods to encourage her child's diet concerning the latter's iron deficiency anemia; which of the following if stated by the mother would indicate the need for further instruction?
- A. Fish
- B. Lean meats
- C. Whole-grain breads
- D. Yellow vegetables
Correct Answer: D
Rationale: Yellow vegetables do not contain a significant amount of iron compared to the other options provided (fish, lean meats, and whole-grain breads). Therefore, if Mrs. Baker indicates that she plans to focus on yellow vegetables to address her child's iron deficiency anemia, further instruction would be necessary to help her choose more iron-rich sources of food to improve her child's condition.
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The nurse is caring for a 5-year-old child with impetigo contagiosa. The parents ask the nurse what will happen to their child's skin after the infection has subsided and healed. Which answer should the nurse give?
- A. There will be no scarring.
- B. There may be some pigmented spots.
- C. It is likely there will be some slightly depressed scars.
- D. There will be some atrophic white scars.
Correct Answer: A
Rationale: Impetigo contagiosa typically does not leave scarring once it has subsided and healed. This skin infection primarily affects the superficial layers of the skin and does not cause damage deep enough to result in scarring. While there may be some temporary pigmented spots or mild changes in skin color after the infection resolves, scarring is not a common outcome of impetigo contagiosa in most cases. Thus, the nurse should reassure the parents that their child's skin is not likely to have any scarring after the infection has healed.
After a 3- month trail of dietary therapy, a client with type2 diabetes mellitus still has blood glucose levels above 180 mg/dl. The physician adds glyburide (DiaBeta), 2.5 mg P.O. daily, to the treatment regimen. The nurse should instruct the client to take glyburide:
- A. 30 minutes before breakfast
- B. 30 minutes after dinner.
- C. in the midmorning
- D. at bedtime.
Correct Answer: D
Rationale: Glyburide (DiaBeta) is a sulfonylurea medication used to treat type 2 diabetes mellitus by stimulating the pancreas to release more insulin. Taking glyburide at bedtime is recommended because it helps to ensure that the medication's peak action aligns with the natural rise in blood glucose levels in the early morning hours, which can help control fasting blood glucose levels. Additionally, taking glyburide in the evening reduces the risk of hypoglycemia during the day when the client may be more active and less likely to monitor blood glucose levels closely.
Which blood gas analyses are most indicative of respiratory acidosis?
- A. pH = 7.22, PCO2 = 55 mmHg, HCO3 = 30 mEq/L.
- B. pH = 7.28, PCO2 = 45 mmHg, HCO3 = 15 mEq/L.
- C. pH = 7.34, PCO2 = 35 mmHg, HCO3 = 25 mEq/L.
- D. pH = 7.40, PCO2 = 25 mmHg, HCO3 = 30 mEq/L.
Correct Answer: A
Rationale: Respiratory acidosis is indicated by a low pH and elevated PCO2, as seen in option A.
A client has type1 diabetes. Her husband finds her unconscious at home and administers glucagons, 0.5 mg S.C. She awakens in 5 minutes .Why her husband offer a complex carbohydrate snack to her as soon as possible?
- A. To decrease the possibility of nausea and vomiting
- B. To restore liver glycogen and prevent secondary hypoglycemia
- C. To stimulate her appetite
- D. To decrease the amount of glycogen in her system
Correct Answer: B
Rationale: Providing a complex carbohydrate snack to the client after she has been treated with glucagon is important to restore liver glycogen and prevent secondary hypoglycemia. Glucagon works by stimulating the liver to release stored glucose, which quickly raises blood sugar levels. However, this can deplete the liver's glycogen stores, making the client susceptible to experiencing hypoglycemia again if additional glucose is not consumed. Offering a complex carbohydrate snack will help replenish the liver's glycogen stores and sustain blood sugar levels to prevent a recurrence of hypoglycemia.
The nurse is caring for a newborn receiving an exchange transfusion for hemolytic disease. Assessment of the newborn reveals slight respiratory distress and tachycardia. Which should the nurse's first action be?
- A. Notify practitioner.
- B. Stop the transfusion.
- C. Administer calcium gluconate.
- D. Monitor vital signs electronically.
Correct Answer: B
Rationale: Slight respiratory distress and tachycardia in a newborn during an exchange transfusion may indicate a possible transfusion reaction or overload. The first action the nurse should take is to stop the transfusion to prevent any further complications and assess the newborn's condition. After stopping the transfusion, the nurse can then take appropriate steps such as notifying the practitioner, administering medications, or providing supportive care as needed.