The LEAST important advice for a 2-month-old baby with excessive crying is
- A. master the situation in relaxed manner
- B. adhere to precry cues
- C. change milk formula
- D. avoid sensory overstimulation
Correct Answer: C
Rationale: Changing formula is less critical if the baby is gaining weight adequately.
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A nurse is planning a teaching session for parents of a newborn who plan to bottle-feed. Which should the nurse include in the teaching session? (Select all that apply.)
- A. Limiting the feeding to 15 minutes
- B. Propping the bottle for night feedings is acceptable
- C. Proper technique for cleansing the bottles and nipples
- D. Feeding infant on alternate sides of the lap
Correct Answer: C
Rationale: Proper technique for cleansing the bottles and nipples - It is essential to educate parents on the proper technique for cleaning bottles and nipples to prevent bacteria growth and ensure the newborn's milk is not contaminated.
Clients will go through operations and who have undergone surgery need the proper observation, treatment, and care. Implementing the nursing process to these patients will help reduce complications. Nurse Maria is preparing Mr. Sy for surgery. Which of the following statements by the client would indicate he is well-informed about his imminent surgery?
- A. " Right after the operation, I will wear the pneumatic compression device while sitting on the chair."
- B. "I will not eat anything after 12 pm the night befire my operation, but I sure can drink."
- C. "The skin preparation site is longer and wider than the actual incision site."
- D. "I will need to sign the consent from after I get to the operating table."
Correct Answer: B
Rationale: Option B, "I will not eat anything after 12 pm the night before my operation, but I sure can drink," indicates that the client understands and is knowledgeable about the pre-operative fasting guidelines. It is crucial for patients to have an empty stomach before surgery to prevent complications related to anesthesia, such as aspiration pneumonia. This statement shows that Mr. Sy is well-informed and compliant with this important pre-operative instruction. Options A, C, and D do not directly demonstrate specific knowledge regarding the surgery preparations.
The nurse is caring for a very low birth weight (VLBW) newborn with a peripheral intravenous infusion. Which statement describes nursing considerations regarding infiltration?
- A. Infiltration occurs infrequently because VLBW newborns are inactive.
- B. Continuous infusion pumps stop automatically when infiltration occurs.
- C. Hypertonic solutions can cause severe tissue damage if infiltration occurs.
- D. Infusion site should be checked for infiltration at least once per 8-hour shift.
Correct Answer: C
Rationale: Infiltration of intravenous fluids in VLBW newborns can lead to serious complications, especially if hypertonic solutions are being administered. Hypertonic solutions have a higher osmolarity than the body's fluids, which can cause severe tissue damage if there is infiltration. It is crucial for the nurse to monitor the infusion site closely for signs of infiltration and take prompt action to prevent further harm to the newborn's delicate skin and tissues. The other options are not directly related to the risk and consequences of infiltration in VLBW newborns.
Which vein should be used first when initiating IV therapy?
- A. Jugular
- B. Basilic
- C. Brachiocephalic
- D. Axillary
Correct Answer: B
Rationale: When initiating IV therapy, the basilic vein is often used first due to its accessibility and size. The basilic vein is a common choice for venipuncture because it is located on the medial aspect of the arm and tends to be easily palpable. Additionally, the basilic vein is also less prone to complications such as nerve damage compared to other deeper veins like the jugular or brachiocephalic veins. Therefore, utilizing the basilic vein as the initial site for IV therapy is a safe and efficient choice.
Which of the following types of cells is the immune system's shutoff mechanism?
- A. Plasma cells
- B. Suppressor T cells
- C. Helper T cells
- D. B lymphocytes
Correct Answer: B
Rationale: Suppressor T cells, also known as regulatory T cells, play a critical role in regulating the immune response by acting as the immune system's shutoff mechanism. These cells help maintain immune tolerance and prevent overactivation of the immune system, thereby preventing autoimmune reactions and excessive inflammation. Suppressor T cells exert their immunosuppressive effects by inhibiting the function of other immune cells, such as effector T cells and B cells, and helping to control the overall balance of the immune system.