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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The nurse is caring for a 9-year-old client with cystic fibrosis who is scheduled to receive pancrelipase at 1200. The client states, 'I am not hungry now. I want to eat lunch in a few hours.' Which of the following actions should the nurse take?
- A. Omit the dose of medication.
- B. Administer half the dose of medication.
- C. Administer the dose of medication with a small snack
- D. Hold the dose of medication until the client is ready to eat.
Correct Answer: C
Rationale: Pancrelipase aids digestion in cystic fibrosis and should be taken with food. A small snack (C) ensures enzyme effectiveness while respecting the child’s appetite. Omitting (A) or halving (B) the dose risks malabsorption, and holding (D) delays nutrition.
The client with malignant left pleural effusion undergoes a thoracentesis and 900 mL of excess pleural fluid is removed. Which of these manifestations, if noted on the post-procedure assessment, should the nurse report to the health care provider immediately?
- A. Asymmetrical chest expansion and decreased breath sounds on the left
- B. Blood pressure 100/65 mm Hg (mean arterial pressure 77 mm Hg)
- C. Client complains of 6/10 pain at the needle insertion site
- D. Respiratory rate 24/min, pulse oximetry 94% on oxygen 2 L/min
Correct Answer: A
Rationale: Asymmetrical chest expansion and decreased breath sounds (A) suggest pneumothorax, a serious post-thoracentesis complication. Hypotension (B), pain (C), and mild tachypnea (D) are less urgent or expected.
A visiting family member of a hospitalized client reports sudden onset of a headache and numbness in half of the body. The visitor asks the nurse to take a blood pressure reading. What is the most appropriate response by the nurse?
- A. Encourage the visitor to lie down to see if symptoms change
- B. Initiate protocol to assist the visitor to the emergency department
- C. Proceed to take the visitor's blood pressure
- D. Suggest that the visitor call the health care provider
Correct Answer: B
Rationale: Sudden headache and hemibody numbness suggest a possible stroke, a medical emergency requiring immediate evaluation. Initiating protocol to transfer the visitor to the emergency department (B) ensures timely care. Lying down (A), taking blood pressure (C), or calling a provider (D) delays critical intervention.
A client with asthma was recently prescribed fluticasone/salmeterol. After the client has received instructions about this medication, which statement would require further teaching by the nurse?
- A. After taking this medication, I will rinse my mouth with water.'
- B. At the first sign of an asthma attack, I will take this medication.'
- C. I have been smoking for 12 years, but I just quit a month ago.'
- D. I received the pneumococcal vaccine about a month ago.'
Correct Answer: B
Rationale: Fluticasone/salmeterol is a maintenance medication for asthma, not a rescue inhaler for acute attacks. Statement B indicates a misunderstanding, requiring further teaching to clarify that a short-acting bronchodilator (e.g., albuterol) should be used for acute symptoms. Rinsing the mouth (A) prevents oral thrush from the steroid component. Quitting smoking (C) and receiving a vaccine (D) are positive health behaviors not requiring correction.
The doctor has ordered two medications to be given intramuscularly. The nurse should:
- A. Ask the doctor to clarify the order.
- B. Give one injection, wait 30 minutes, and give the other.
- C. Determine whether the medications can be combined.
- D. Administer the injections, one in each hip.
Correct Answer: C
Rationale: The nurse must check if the medications are compatible for combination in one syringe to minimize injections. Administering separately without checking or in specific sites is premature.