Nokea
The mother of a 2-month-old child asks the nurse when she should start her son on solids. He is taking about 30 oz of formula per day. How should the nurse respond?
- A. This is a good time to begin.'
- B. When he is taking a quart per day.'
- C. Babies usually are ready for solids between 4 and 6 months of age.'
- D. Each baby is different. Some are ready sooner than others.'
Correct Answer: C
Rationale: Solids are typically introduced between 4-6 months when infants have better head control and digestive maturity, not at 2 months or based on formula volume.
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The nurse is caring for a client with a history of type 1 diabetes who is receiving insulin lispro (Humalog) 8 units subcutaneously before meals. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood glucose of 90 mg/dL.
- B. Heart rate of 80 bpm.
- C. Sweating and confusion.
- D. Blood pressure of 120/80 mmHg.
Correct Answer: C
Rationale: Sweating and confusion indicate hypoglycemia, a serious complication of insulin lispro, requiring immediate treatment with carbohydrates. Options A, B, and D are normal: glucose 90 mg/dL, heart rate 80 bpm, and blood pressure 120/80 mmHg indicate stability.
A client returned from surgery for a perforated appendix with localized peritonitis. In view of this diagnosis, how would the nurse position the client?
- A. Prone
- B. Dorsal recumbent
- C. Semi-Fowler
- D. Supine
Correct Answer: C
Rationale: Semi-Fowler. The semi-Fowler position assists drainage and prevents spread of infection throughout the abdominal cavity.
A client receiving HTZ (hydrochlorothiazide) is instructed to increase her dietary intake of potassium. The best snack for the client requiring increased potassium is:
- A. A pear
- B. An apple
- C. An orange
- D. A banana
Correct Answer: D
Rationale: Hydrochlorothiazide is a diuretic that can cause potassium loss. Bananas are high in potassium, making them the best choice. Pears , apples , and oranges have less potassium.
An infant admitted to the pediatric unit with possible Haemophilus influenzae meningitis.
Which of the following should be the nursing priority for an infant admitted to the pediatric unit with possible Haemophilus influenzae meningitis?
- A. Encourage intake of oral fluids to prevent dehydration.
- B. Restrain the child appropriately to maintain the integrity of the IV site.
- C. Place the child on droplet precautions.
- D. Encourage the parents to hold and rock the infant to promote comfort.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) fluid requirements are determined by child's hydration status; fluids are usually limited to prevent cerebral edema (2) not a priority (3) correct-to prevent spread of infection, child is placed on droplet precautions for at least 24 hours after implementation of antibiotic therapy (4) would cause discomfort to infant's head
An elderly client is admitted to a skilled nursing care facility. When doing a skin assessment, the nurse notes a 3-cm round area of partial-thickness skin loss that looks like a blister on the client's sacrum. The nurse interprets this to be a:
- A. stage I pressure ulcer.
- B. stage II pressure ulcer.
- C. stage III pressure ulcer.
- D. stage IV pressure ulcer.
Correct Answer: B
Rationale: A stage II pressure ulcer involves partial-thickness skin loss, often presenting as a blister or shallow open ulcer, matching the description. Stage I is non-blanchable erythema, stage III involves full-thickness loss, and stage IV extends to muscle/bone.