Nokea
The nurse in the outpatient clinic is caring for a client whose obstetric history is documented as G3 T1 P2 A1 L2. The nurse should recognize that the client
- A. has 3 living children
- B. is currently not pregnant
- C. had 1 live birth after 37 weeks gestation
- D. had 3 births between 20 weeks and 36 weeks gestation
Correct Answer: C
Rationale: G3 indicates 3 pregnancies; T1 means 1 term birth (37 weeks); P2 means 2 preterm births (20-36 weeks); A1 means 1 abortion; L2 means 2 living children. Thus, C is correct as it matches T1.
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The nurse has taught the parents of a 6-year-old client with cystic fibrosis who has a prescription for pancreatic enzymes. Which of the following statements by a parent would require follow-up?
- A. It is acceptable for my child to chew the medication before swallowing it
- B. I should give the medication with or just before my child has a meal or snack
- C. I need to monitor the total amount of medication that I give to my child every day.
- D. It is acceptable to open the capsule and sprinkle the medication on a tablespoon of applesauce.
Correct Answer: A
Rationale: Chewing pancreatic enzymes destroys the enteric coating, reducing efficacy. Timing with meals , monitoring doses , and sprinkling on applesauce are correct practices.
The nurse is talking with the parents of a 2 year old client about nutritional choices to promote growth and development. The family observes a strict vegan diet. Which of the following information should the nurse include? Select all that apply.
- A. Diets consisting of legumes as the only protein source are sufficient for growth.
- B. Green, leafy vegetables such as cabbage and broccoli are good sources of calcium.
- C. Preparing meals with vegetables and fruits will ensure sufficient vitamin B12 intake
- D. Sunlight, mushrooms, and fortified,subscribe plant based milks are good sources of vitamin D.
- E. Try to consume foods high in iron with foods high in vitamin C to increase iron absorption.
Correct Answer: B,D,E
Rationale: Leafy greens provide calcium, sunlight/mushrooms/fortified milks supply vitamin D, and vitamin C with iron enhances absorption. Legumes alone lack essential amino acids, and vegetables/fruits don't provide B12.
The nurse is providing care in the home to a person who has AIDS. Which behavior, if observed by the nurse, indicates a need for further instruction?
- A. The client uses the same dishes as the rest of the family.
- B. The client shares a bathroom with the rest of the family.
- C. The client and his brother use the same razor.
- D. The client often cooks for the family.
Correct Answer: C
Rationale: Sharing razors risks bloodborne HIV transmission, requiring education. Using shared dishes, bathrooms, or cooking poses no significant risk with standard precautions.
The nurse is discussing iron deficiency anemia with a community group. Which of the following persons are at risk for iron deficiency anemia? Select all that apply.
- A. A 15-month-old who drinks a lot of milk
- B. A 6-year-old who has sickle cell anemia
- C. An adolescent female
- D. A woman who is 8 months pregnant
- E. An African-American middle-aged man
- F. A 78-year-old on a fixed income
Correct Answer: A,C,D,F
Rationale: Toddlers drinking excessive milk, adolescent females (due to menstruation), pregnant women (increased iron demand), and elderly on fixed incomes (poor diet) are at risk. Sickle cell anemia and African-American males are not specific risk factors.
The nurse is observing a staff member perform ear irrigation for an adult client with impacted cerumen. The nurse should intervene if the staff member is observed
- A. using a slow, steady flow of solution to irrigate the ear canal
- B. placing the client in a lying position with the head tilted toward the affected ear
- C. straightening the ear canal by pulling the pinna down and back
- D. directing the tip of the syringe and irrigation solution toward the top of the ear canal
Correct Answer: C
Rationale: Pulling the pinna down and back is incorrect for adults; it should be up and back. Slow flow , head tilt , and directing solution upward are correct.