Nokea
The nurse is caring for a 2 month-old infant with a congenital heart defect. Which of the following is a priority nursing action?
- A. Provide small feedings every 3 hours
- B. Maintain intravenous fluids
- C. Add strained cereal to the diet
- D. Change to reduced calorie formula
Correct Answer: A
Rationale: Infants with congenital heart defects are at increased risk for developing congestive heart failure. Infants with congestive heart failure have an increased metabolic rate and require additional calories to grow. At the same time, however, rest and conservation of energy for eating is important. Feedings should be smaller and every 3 hours rather than the usual 4 hour schedule.
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Which of the following musical instruments is best for a teen with asthma?
- A. Guitar
- B. Piano
- C. Drums
- D. Clarinet
Correct Answer: A
Rationale: The guitar does not require breath control, making it suitable for a teen with asthma, unlike wind instruments like the clarinet.
The best choice for the child following a tonsillectomy is:
- A. Fruit punch
- B. Grape soda
- C. A banana Popsicle
- D. Ice cream
Correct Answer: C
Rationale: A banana Popsicle is soothing, cold, and non-irritating to the surgical site. Liquids like punch or soda may sting, and ice cream is dairy, which can increase mucus.
The clinic nurse is collecting data on a client at 22 weeks gestation during a prenatal visit. Which finding is most concerning?
- A. Client has not consistently taken prenatal vitamins
- B. Client is taking lisinopril to control hypertension
- C. Client reports a whitish vaginal discharge
- D. Client reports mild cramping pain in the lower abdomen
Correct Answer: B
Rationale: Lisinopril is contraindicated in pregnancy due to the risk of fetal harm and requires immediate discontinuation.
In the past 12-month period, a man has been arrested twice for driving while intoxicated. He is able to perform his activities of daily living without the use of alcohol and restricts his drinking to weekends. This client meets the criteria for which of the following?
- A. Alcohol withdrawal syndrome
- B. Bad judgment syndrome
- C. Substance abuse
- D. Substance dependence
Correct Answer: C
Rationale: Repeated legal issues from weekend drinking indicate substance abuse, as it causes significant impairment without daily dependence.
The nurse is preparing to flush a client's central venous catheter. Which size syringe is best for the nurse to choose?
- A. 1 mL
- B. 3 mL
- C. 10 mL
- D. 30 mL
Correct Answer: C
Rationale: A 10 mL syringe is recommended to avoid excessive pressure that could damage the catheter.