Nokea
The clinic nurse is caring for several clients during well-child visits. The nurse should recognize which client as being the most at risk for anemia?
- A. 1-month-old infant born at term gestation who exclusively breastfeeds
- B. 2-month-old infant born at preterm gestation who exclusively receives iron-fortified formula
- C. 3-month-old infant born at preterm gestation who is exclusively bottle-fed with breastmilk
- D. 4-month-old infant born at term gestation who breastfeeds and eats iron-fortified infant cereal
Correct Answer: C
Rationale: A preterm infant bottle-fed with breastmilk is most at risk for anemia due to preterm infants' lower iron stores and breastmilk's low iron content. Term breastfed infants (A, D) have adequate stores initially, and iron-fortified formula prevents anemia.
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The client with herpes zoster will most likely have an order for which category of medication?
- A. Antibiotics
- B. Antipyretics
- C. Antivirals
- D. Anticoagulants
Correct Answer: C
Rationale: Herpes zoster, caused by the varicella-zoster virus, is treated with antivirals like acyclovir to reduce severity and duration. Antibiotics, antipyretics, and anticoagulants are not primary treatments.
The nurse responds to the call light of a client with chronic obstructive pulmonary disease (COPD) who says, 'I can't breathe.' The client seems to be having difficulty breathing and is nervous and tremulous. Vital signs are stable, oxygen saturation is 92% on 2 L, and there are clear breath sounds bilaterally. Which intervention would be most appropriate at this time?
- A. Administer albuterol nebulizer
- B. Assist the client in identifying the trigger and ways to avoid it
- C. Coach the client through controlled breathing exercises
- D. Continue to monitor oxygen saturation
Correct Answer: C
Rationale: For a COPD client with anxiety-driven dyspnea, stable vitals, and clear lungs, coaching controlled breathing helps reduce anxiety and improve breathing patterns. Albuterol is for bronchospasm, trigger identification is secondary, and monitoring is insufficient alone.
A nurse in a school health clinic is reinforcing teaching for the parent of a young client with pediculosis capitis. Which statement by the parent indicates understanding of the teaching?
- A. I will launder recently worn clothing, sheets, and towels in hot water.'
- B. I will make sure all eating utensils are placed in the dishwasher.'
- C. I will spray the house with insecticide to control this problem.'
- D. I will throw away stuffed animals and toys that cannot be washed.'
Correct Answer: A
Rationale: Laundering clothing, sheets, and towels in hot water effectively kills lice and nits, indicating understanding. Dishwashing utensils is irrelevant, spraying insecticide is unnecessary, and discarding toys is excessive if they can be sealed or washed.
The parent of a 7-month-old reports that the child has been crying and vomiting with a distended belly for the past 4 hours. The infant is now lying quietly in the parent's arms with a pulse of 200/min and respirations of 60/min. Which of the following components of SBAR (situation, background, assessment, recommendation/read back) communication is most important for the nurse to report?
- A. Client has been ill for approximately 4 hours
- B. Client has improved from apparent earlier distress
- C. Client is now lethargic with abnormal vital signs
- D. Does the health care provider want to order a laxative?
Correct Answer: C
Rationale: The infant's lethargy with tachycardia (200/min) and tachypnea (60/min) are critical, suggesting a serious condition like intussusception or volvulus, requiring urgent reporting. Duration , perceived improvement , and laxative suggestion are less critical.
The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing?
- A. Apply dressing using sterile technique
- B. Improve the client's nutrition status
- C. Initiate limb elevation and compression
- D. Begin proteolytic debridement
Correct Answer: B
Rationale: The goal of clinical management in a client with venous stasis ulcers is to promote healing. This only can be accomplished with proper nutrition. The other interventions are appropriate, but without proper nutrition, they would be of little help.