Nokea
The nurse is beginning nutritional counseling/teaching with a pregnant woman. What is the initial step in this interaction?
- A. Teach her how to meet the needs of self and her family
- B. Explain the changes in diet necessary for pregnant women
- C. Question her understanding and use of the food pyramid
- D. Conduct a diet history to determine her normal eating routines
Correct Answer: D
Rationale: Assessment is always the first step in planning teaching for any client. A thorough and accurate history is essential for gathering the needed information.
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The nurse is providing home care for a client with heart failure and pulmonary edema. Which nursing diagnosis should have priority in planning care?
- A. Impaired skin integrity related to dependent edema
- B. Activity intolerance related to oxygen supply and demand imbalance
- C. Constipation related to immobility
- D. Risk for infection related to ineffective mobilization of secretions
Correct Answer: B
Rationale: Activity intolerance related to oxygen supply and demand imbalance. This is the primary problem due to decreased cardiac output related to heart failure. There is a reduction of oxygen, leading to findings of dyspnea and fatigue.
The nurse just administered routine immunizations to a healthy 15-month-old. What information should the nurse reinforce with the caregivers before they leave the clinic?
- A. Call the office if the toddler's temperature is higher than 100 F (37.7 C)
- B. Fussiness and anorexia are common for 1 week after immunizations
- C. Redness at the injection sites and a mild fever are common
- D. The toddler's activity level should be restricted for 24 hours
Correct Answer: C
Rationale: Redness and mild fever (C) are common post-immunization reactions. A temperature above 100 F (A) is too low a threshold for concern, fussiness for a week (B) is excessive, and activity restriction (D) is unnecessary.
The nurse assigns an unlicensed assistive personnel (UAP) to care for a client with a musculoskeletal disorder. The client ambulates with a leg splint. Which task requires supervision of the UAP?
- A. Report signs of redness overlying a joint
- B. Monitor the client's response to ambulatory activity
- C. Encouragement for the independence in self-care
- D. Assist the client to transfer from a bed to a chair
Correct Answer: B
Rationale: Monitor the client's response to interventions requires assessment, a task to be performed by an RN.
A postoperative client is having difficulty voiding. Palpation of the bladder indicates that the bladder is full. What should the nurse do initially?
- A. Ask the physician for a catheterization order
- B. Pour water over the client's perineum
- C. Encourage the client to take deep breaths
- D. Administer pain medication
Correct Answer: B
Rationale: Pouring water over the perineum stimulates the micturition reflex, aiding voiding non-invasively. Catheterization, breathing, or pain medication are secondary.
The nurse is discussing child safety with a group of mothers of toddlers. Which statement indicates a need for more instruction?
- A. My child should be in the back seat in a front-facing car seat.'
- B. My little one needs constant supervision.'
- C. My child eats finger foods.'
- D. I should put my medicines on a high shelf.'
Correct Answer: A
Rationale: Toddlers (under 2 years) should be in rear-facing car seats for safety; front-facing is incorrect, indicating a need for further instruction.