Nokea
The mother of a 6-year-old anemic boy is taught by the nurse to give iron supplements. Which statement indicates that the mother understands the proper administration of iron?
- A. The iron tablets will be absorbed between meals, on an empty stomach
- B. I should give the iron tablets with his milk and cereal each morning
- C. Iron preparations can be taken with antibiotics if he develops an infection
- D. The iron tablets may cause him to sunburn more easily so he should wear sunscreen
Correct Answer: A
Rationale: The correct answer is A because iron supplements are best absorbed on an empty stomach, which maximizes their effectiveness. Giving iron tablets with milk or calcium-rich foods, as mentioned in choice B, should be avoided as they can decrease iron absorption. Choice C is incorrect because iron preparations should not be taken with antibiotics due to potential interactions. Choice D is also incorrect as iron tablets do not cause an increased risk of sunburn, so sunscreen is not necessary specifically due to iron supplementation.
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A client with a small bowel obstruction is experiencing frequent vomiting. Which instructions are most important for the nurse to provide to the unlicensed assistive personnel (UAP) who is completing morning care for this client?
- A. Maintain a quiet environment
- B. Ensure the linens are clean and dry
- C. Place an air deodorizer in the room
- D. Measure all emesis accurately
Correct Answer: D
Rationale: The correct answer is D, 'Measure all emesis accurately.' When a client with a small bowel obstruction is experiencing frequent vomiting, measuring emesis accurately is crucial for monitoring fluid balance and preventing dehydration. Choice A, 'Maintain a quiet environment,' while important for patient comfort, is not as critical as accurately measuring emesis. Choices B and C, 'Ensure the linens are clean and dry' and 'Place an air deodorizer in the room,' focus on environmental factors that, although helpful, are not as essential as monitoring the client's fluid balance in this situation.
Which assessment finding should indicate to the nurse that a client with arterial hypertension is experiencing a cardiac complication?
- A. Complaints of an occipital headache
- B. A palpable dorsal pedis pulse bilaterally
- C. Complaints of shortness of breath on exertion
- D. A blood pressure of 160/90
Correct Answer: C
Rationale: The correct answer is C, complaints of shortness of breath on exertion. This symptom is indicative of heart failure, a common cardiac complication of arterial hypertension. Shortness of breath on exertion is often due to the heart's inability to pump effectively, leading to fluid buildup in the lungs. Choices A, B, and D are incorrect because complaints of an occipital headache, a palpable dorsal pedis pulse bilaterally, and a blood pressure of 160/90 do not specifically indicate a cardiac complication in a client with arterial hypertension.
An 18-year-old gravida 1, at 41-weeks gestation, is undergoing an oxytocin (Pitocin) induction and has an epidural catheter in place for pain control. With each of the last three contractions, the nurse notes a late deceleration. The client is repositioned and oxygen provided, but the late decelerations continue to occur with each contraction. What action should the nurse take first?
- A. Prepare for immediate cesarean birth
- B. Turn off the oxytocin (Pitocin) infusion
- C. Notify the anesthesiologist that the epidural infusion needs to be disconnected
- D. Apply an internal fetal monitoring device and continue to monitor carefully
Correct Answer: B
Rationale: In the scenario described, the presence of late decelerations during contractions indicates fetal compromise. To address this, the nurse's initial action should be to turn off the oxytocin (Pitocin) infusion. Oxytocin can contribute to uteroplacental insufficiency, leading to late decelerations. This intervention aims to improve fetal oxygenation and prevent further stress on the fetus. Immediate cesarean birth is not the first-line action unless other interventions fail. Notifying the anesthesiologist about disconnecting the epidural infusion is not the priority in this situation. Applying an internal fetal monitoring device is invasive and not the immediate step needed when late decelerations are present.
A client with chronic renal failure is being discharged with a prescription for erythropoietin (Epogen). Which statement indicates that the client understands the action of this medication?
- A. It helps my body make red blood cells
- B. It helps prevent infections
- C. It helps my kidneys excrete excess fluid
- D. It helps me breathe easier
Correct Answer: A
Rationale: The correct answer is A: 'It helps my body make red blood cells.' Erythropoietin is a medication that stimulates the production of red blood cells in the body. Clients with chronic renal failure often develop anemia due to decreased erythropoietin production by the kidneys. This medication helps address that issue by increasing red blood cell production. Choices B, C, and D are incorrect because erythropoietin does not prevent infections, help kidneys excrete excess fluid, or assist with breathing; its primary action is to boost red blood cell production.
An adult male is admitted to the psychiatric unit from the emergency department because he is in the manic disorder. He has lost 10 pounds in the last two weeks and has not bathed in a week because he has been 'trying to start a new business' and is 'too busy to eat.' He is alert and oriented to time, place and person, but not situation. Which nursing diagnosis has the greatest priority?
- A. Self-care deficit
- B. Disturbed sleep pattern
- C. Disturbed thought processes
- D. Imbalanced nutrition
Correct Answer: D
Rationale: Imbalanced nutrition is the most critical nursing diagnosis to address in this scenario. The patient's significant weight loss and neglect of basic needs, such as eating and personal hygiene, indicate a severe imbalance in nutrition. Addressing this issue is crucial to prevent further health deterioration. Self-care deficit, disturbed sleep pattern, and disturbed thought processes are important but secondary concerns compared to the immediate risk posed by imbalanced nutrition. While self-care deficit and disturbed sleep pattern are valid concerns, the patient's weight loss and neglect of basic needs take precedence. Disturbed thought processes are also significant but addressing the imbalanced nutrition is more urgent in this context.