Nokea
The mother of a 3 month-old infant tells the nurse that she wants to change from formula to whole milk and add cereal and meats to the diet. What should be emphasized as the nurse teaches about infant nutrition?
- A. Solid foods should be introduced at 3-4 months
- B. Whole milk is difficult for a young infant to digest
- C. Fluoridated tap water should be used to dilute milk
- D. Supplemental apple juice can be used between feedings
Correct Answer: B
Rationale: Cow's milk is not given to infants younger than 1 year because the tough, hard curd is difficult to digest. In addition, it contains little iron and creates a high renal solute load.
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The care of which of the following clients can the nurse safely delegate to an unlicensed assistive personnel (UAP)?
- A. A client with peripheral vascular disease and an ulceration of the lower leg.
- B. A pre-operative client awaiting adrenalectomy with a history of asthma
- C. An elderly client with hypertension and self-reported non-compliance
- D. A new admission with a history of transient ischemic attacks and dizziness
Correct Answer: A
Rationale: This client is stable with no risk of instability as compared to the other clients. The client has a chronic condition and needs supportive care, which is appropriate for a UAP.
Because a client has Guillain-Barré syndrome, the nurse would expect which of the following in the client's history?
- A. Recent upper respiratory infection
- B. A tick bite a few days ago
- C. A mosquito bite a week ago
- D. A strep throat infection two weeks ago
Correct Answer: A
Rationale: Guillain-Barré syndrome is often preceded by a viral upper respiratory infection, triggering an autoimmune response, unlike tick bites, mosquito bites, or strep throat.
The mother of a 3-year-old hospitalized with lead poisoning asks the nurse to explain the treatment for her daughter. The nurse's explanation is based on the knowledge that lead poisoning is treated with:
- A. Gastric lavage
- B. Chelating agents
- C. Antiemetics
- D. Activated charcoal
Correct Answer: B
Rationale: Chelating agents , like succimer, bind lead for excretion. Gastric lavage and charcoal are ineffective for systemic lead. Antiemetics treat symptoms, not the cause.
The licensed practical nurse is assisting the RN with preparation for administering a transfusion of whole blood. Which action by the nurse predisposes the client to the development of hyperkalemia?
- A. Allowing the blood to warm to room temperature
- B. Administering blood that is 24 hours old
- C. Administering blood with an 18-gauge needle
- D. Filling the drip chamber below the level of the filter
Correct Answer: A
Rationale: Allowing blood to warm to room temperature can cause red blood cells to hemolyze, releasing potassium and increasing the risk of hyperkalemia.
A mother brings her 26 month-old to the well-child clinic. She expresses frustration and anger due to her child's constantly saying 'no' and his refusal to follow her directions. The nurse explains this is normal for his age, as negativism is attempting to meet which developmental need?
- A. Trust
- B. Initiative
- C. Independence
- D. Self-esteem
Correct Answer: C
Rationale: Independence. In Erikson's theory of development, toddlers struggle to assert independence, often using the word 'no' to establish autonomy.