Nokea
The clinic nurse is interviewing the parents of a 6-month-old client about the infant's diet. Which statement by the parents is most concerning?
- A. Because apples are healthy, we make apple pie and feed small, soft bites to our baby.
- B. If our baby refuses to finish foods, we continue to offer small bites, so food isn't wasted.
- C. Infant oatmeal sweetened with fresh honey is our baby's favorite breakfast.
- D. We found that the food in TV dinners can be easily pureed and is convenient.
Correct Answer: C
Rationale: Honey poses a botulism risk in infants under 1 year, making it the most concerning. Apple pie and TV dinners are inappropriate but less dangerous, and offering bites is not harmful.
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Which of the following tasks can the nurse assign to an unlicensed assistive personnel (UAP)?
- A. assisting a client with ambulating to the bathroom for the first time following surgery
- B. expiated client with dementia who has a serum glucose level of 70 mg/dL (3.9 mmol/L)
- C. explaining why incentive spirometer use is important to a client with postoperative pneumonia
- D. taking vital signs every 15 minutes on a client who was just transferred from the postanesthesia recovery unit
Correct Answer: D
Rationale: Taking vital signs is within UAP scope. First-time ambulation , hypoglycemia , and teaching require nursing judgment.
The nurse is giving unlicensed assistive personnel directions for bathing a client who has a surgical incision infected with methicillin-resistant Staphylococcus aureus. Which instructions would be most effective for reducing infection?
- A. Assist the client to the shower and provide directions to use antibacterial soap
- B. Delay the bath until the client has received antibiotic therapy for 24 hours
- C. Use a bath basin with warm water and a new washcloth for each body area
- D. Use packaged pre-moistened cloths containing chlorhexidine to bathe the client
Correct Answer: D
Rationale: Chlorhexidine cloths effectively reduce MRSA. Antibacterial soap is less specific, delaying the bath is unnecessary, and a bath basin risks contamination.
The nurse is caring for a client who is receiving an intravenous infusion. Which finding would indicate that the client's IV has infiltrated?
- A. The client's arm is red and warm to the touch.
- B. The IV is running faster than the desired rate.
- C. The area around the infusion site is pale and cool to the touch.
- D. The client complains of severe pain up and down the arm.
Correct Answer: C
Rationale: Infiltration causes pale, cool skin around the IV site due to fluid leakage into tissues. Redness, fast infusion, or radiating pain suggest other issues.
The nurse is reinforcing teaching about newly prescribed clonidine for a client with hypertension. Which of the following information would be most important for the nurse to reinforce?
- A. Avoid consuming high-sodium foods
- B. Do not stop taking the medication abruptly
- C. Limit alcohol intake while taking the medication
- D. Use an oral moisturizer to relieve dry mouth
Correct Answer: B
Rationale: Abruptly stopping clonidine can cause rebound hypertension, a critical risk. Sodium , alcohol , and dry mouth are less urgent.
A client scheduled for a femoral popliteal bypass is to be assigned to a semi-private room. Which client would be the most suitable roommate for the client with a femoral popliteal bypass graft?
- A. A client with a pituitary tumor
- B. A client with respiratory sarcoidosis
- C. A client with a diabetic ulcer
- D. A client with a closed fracture of femur
Correct Answer: A
Rationale: The client with a pituitary tumor is the most suitable roommate as they are unlikely to have an infectious condition or mobility issues that could complicate recovery. Respiratory sarcoidosis may involve respiratory issues, increasing infection risk. A diabetic ulcer poses an infection risk due to potential open wounds. A closed femur fracture may involve similar mobility restrictions, complicating room logistics.