Nokea
The nurse is caring for a 2-year-old client who has iron deficiency anemia. The nurse should recognize that this condition is most likely the result of
- A. impaired iron transfer from the mother
- B. excessive intake of meat products
- C. excessive intake of cow's milk
- D. gastrointestinal blood loss
Correct Answer: C
Rationale: Excessive cow's milk intake in toddlers can lead to iron deficiency anemia due to low iron content and potential for gastrointestinal irritation.
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The home health nurse is contributing to the plan of care for a 1-year-old client recently diagnosed with failure to thrive. Which of the following interventions should the nurse recommend including in the client's plan of care? Select all that apply.
- A. Assess overall parenting skills and access to resources
- B. Observe both the client and the parents during feedings
- C. Monitor the client's height, weight, and head circumference
- D. Ask the parents about the client's dietary intake over the past 24 hours
- E. Discuss with the parents the need to insert a nasogastric tube for enteral feedings
Correct Answer: A,B,C,D
Rationale: Assessing parenting, observing feedings, monitoring growth, and reviewing intake identify causes of failure to thrive. Nasogastric tubes are not initially indicated.
The nurse is observing a client who had a left total knee replacement using a cane to descend stairs. It would demonstrate correct technique if the client descends the stairs by placing the
- A. cane on the step first, followed by the affected leg, and then the unaffected leg
- B. cane on the step first, followed by the unaffected leg, and then the affected leg
- C. affected leg on the step first, followed by the cane, and then the unaffected leg
- D. unaffected leg on the step first, followed by the affected leg, and then the cane
Correct Answer: A
Rationale: For descending stairs, the cane and affected leg move together after the unaffected leg, providing stability.
Which of the following is not considered one of the five rights of medication administration?
- A. client
- B. drug
- C. dose
- D. routine
Correct Answer: D
Rationale: Dose, client, drug, route and time are considered the five rights of medication.
A nursing diagnosis of 'ineffective airway clearance related to pain' is identified for a client who had open abdominal surgery 2 days ago. Which intervention should the nurse implement first?
- A. Administer prescribed analgesic medication for incisional pain
- B. Encourage use of incentive spirometer every 2 hours while awake
- C. Offer an additional pillow to splint the incision while coughing
- D. Promote increased oral fluid intake
Correct Answer: A
Rationale: Pain control is the priority to enable effective coughing and airway clearance.
A 2 year-old child has recently been diagnosed with cystic fibrosis. The nurse is teaching the parents about home care for the child. Which of the following information is appropriate for the nurse to include?
- A. Allow the child to continue normal activities
- B. Schedule frequent rest periods
- C. Limit exposure to other children
- D. Restrict activities to inside the house
Correct Answer: A
Rationale: Allow the child to continue normal activities. Physical activity supports autonomy and mucus secretion in cystic fibrosis.