Nokea
The nurse has reinforced teaching about formula preparation with the parent of a newborn. Which of the following statements by the parent would indicate a correct understanding of the teaching? Select all that apply.
- A. I should avoid using the microwave to heat my baby's formula.
- B. I must wash the top of the concentrated formula can before opening it.
- C. If my baby is feeding poorly, I should use less water to dilute the formula.
- D. Prepared formula should be kept in the refrigerator and discarded after 24 hours.
- E. Bottled water does not need to be boiled when used to reconstitute powdered formula.
Correct Answer: A,B,D
Rationale: Microwaving (A) can cause uneven heating, risking burns, so it’s avoided. Washing the can top (B) prevents contamination. Refrigerated formula must be discarded after 24 hours (D) to prevent bacterial growth. Diluting less (C) alters nutrition, and bottled water (E) may need boiling depending on safety, indicating incorrect understanding.
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While caring for a woman who delivered a healthy term infant six hours ago, the nurse notes that the fundus is soft, 2 cm above the umbilicus, and off to the left. The lochia is red. The nurse suspects that the client has which problem?
- A. Retained placental fragments
- B. Perineal laceration
- C. Urinary retention
- D. Normal involution
Correct Answer: C
Rationale: A soft, displaced fundus suggests urinary retention, causing bladder pressure on the uterus. Normal involution shows a firm, midline fundus; fragments or lacerations present differently.
The nurse is caring for a client with hyperparathyroidism who had a parathyroidectomy 4 hours ago. Which technique should the nurse use to check for complications in this client?
- A. Ask the client to place the backs of the hands against each other to provide hyperextension of the wrist while the elbows remain flexed
- B. Perform the Romberg test by asking the client to stand with the eyes closed and the feet together
- C. Place a blood pressure (BP) cuff on the client's arm, inflate to pressure greater than systolic BP, and monitor for carpal spasm
Correct Answer: C
Rationale: Post-parathyroidectomy, hypocalcemia is a potential complication due to reduced parathyroid hormone levels. Trousseau’s sign (C), elicited by inflating a BP cuff to induce carpal spasm, indicates hypocalcemia, a critical complication requiring prompt intervention. The wrist hyperextension test (A) is unrelated to hypocalcemia, and the Romberg test (B) assesses balance, not relevant to this scenario.
An 8-year-old hospitalized due to a bowel obstruction is to be discharged home with a temporary colostomy. The parents’ primary language is Vietnamese, and their English proficiency is very limited. What is the best approach for the nurse to use when reinforcing instructions to the parents on how to care for the child at home?
- A. Demonstrate the procedure using simple English phrases
- B. Give the parents written instructions with picture illustrations
- C. Tell the parents to have a friend or relative come in to translate
- D. Use an interpreter via the telephone interpretation service
Correct Answer: D
Rationale: A professional interpreter (D) ensures accurate communication, critical for colostomy care. Simple English (A) risks misunderstanding, pictures (B) are insufficient alone, and informal translators (C) may lack medical accuracy.
The nurse is observing a client with an obsessive-compulsive disorder in an inpatient setting. Which behavior is consistent with this diagnosis?
- A. Repeatedly checking that the door is locked
- B. Verbalized suspicions about thefts
- C. Preference for consistent caregivers
- D. Repetitive, involuntary movements
Correct Answer: A
Rationale: Behaviors that are repeated are symptomatic of obsessive-compulsive disorders. These behaviors, performed to reduce feelings of anxiety, often interfere with normal function and employment.
A category 4 hurricane has affected a rural, local health care system, creating a significant increase in emergency department admissions. Which of the following clients should the nurse anticipate as the priority for intervention?
- A. Client with status asthmaticus and a pulse oximetry reading of 89%
- B. Client with diabetes mellitus reporting a headache after being involved in a minor motor vehicle collision
- C. Client who is 11 weeks pregnant, has gestational diabetes, and nausea and vomiting over the past 2 days
- D. Client with diabites mellitus with a serum glucose level of 690 mg/dl (38.3 mmol/L ,abdominal pain, and fatigue)
Correct Answer: A
Rationale: Status asthmaticus with 80% pulse oximetry (A) indicates severe hypoxia, requiring immediate intervention to prevent respiratory failure. Headache post-collision (B) and nausea in pregnancy (C) are less acute, as they do not indicate immediate life-threatening conditions.