Nokea
The nurse is caring for a newborn who has a cleft palate. Which of the following actions should the nurse take to promote oral intake? Select all that apply.
- A. Use specialty bottles or nipples
- B. Burp the newborn often when feeding
- C. Feed the newborn in an upright position
- D. Initiate feeding as soon as possible after birth
- E. Encourage the mother to exclusively breastfeed
Correct Answer: A,B,C
Rationale: Specialty bottles, frequent burping, and upright positioning facilitate feeding and reduce aspiration risk in cleft palate. Early feeding is appropriate but not specific, and exclusive breastfeeding is often challenging.
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The nurse is reinforcing discharge teaching for a client who had aortic valve replacement with a mechanical heart valve. Which statement by the client indicates that teaching has been effective?
- A. I'm glad that I can continue taking my Ginkgo biloba.
- B. I will increase my intake of leafy green vegetables
- C. I will start applying vitamin E to my chest incision after showering
- D. I will shave with an electric razor from now on
Correct Answer: D
Rationale: Mechanical prosthetic valves are more durable than biological valves but require long-term anticoagulation therapy due to the increased risk of thromboembolism. The client should be taught ways to reduce the risk of bleeding.
During morning rounds, the nurse notices that a client who was admitted 3 days ago with hepatic encephalopathy is sleepy and confused. The client is scheduled for discharge later today. Which interventions are appropriate for the nurse to implement? Select all that apply.
- A. Compare current mental status to previous findings
- B. Encourage the client to ambulate in the hallway
- C. Hold the client's morning dose of lactulose
- D. Monitor the client's ammonia level
- E. Observe the client's hand movements with the arms extended
Correct Answer: A,D,E
Rationale: Comparing mental status, monitoring ammonia, and observing for asterixis (hand flapping) assess worsening encephalopathy, delaying discharge. Ambulation is unsafe, and holding lactulose may worsen symptoms.
Following a motor vehicle accident, the client does not know where he is or what year it is and has short-term memory impairment. Which nursing action is most appropriate?
- A. Offer several choices to the client.
- B. Give simple directions to the client.
- C. Give the client the details of the care.
- D. Offer written instructions to the client.
Correct Answer: B
Rationale: Simple directions accommodate memory impairment and disorientation, enhancing comprehension and safety post-accident.
The nurse in the outpatient care facility is caring for a client with metastatic lung cancer who received chemotherapy 3 days ago. The client states, 'I have decided that I do not want to continue treatment.' Which of the following responses would be appropriate for the nurse to make?
- A. That is not an easy choice to make. I will notify your health care provider of your decision
- B. Have you considered how this decision might affect your spouse and children?
- C. I do not think it is wise to stop chemotherapy. You will become too sick to enjoy your life
- D. Have you discussed this decision with someone else that you trust?
Correct Answer: A
Rationale: Acknowledging the decision’s difficulty and notifying the provider respects autonomy and ensures follow-up. Other responses judge, guilt, or deflect the client’s choice.
Medication administration record
Allergies: None
Medications Time
Gabapentin: 300 mg orally, every 8 hours 0700, 1500, and 2300
Hydrocodone/acetaminophen: (5 mg/325 mg) orally, every 4 hours Every 4 hours prn
Acetaminophen: 1,000 mg IV, every 6 hours 0600, 1200, 1800, and 2400
Phenytoin: 100 mg orally, every 12 hours 0700 and 1900
The practical nurse on the neurosurgery step-down unit is assisting the registered nurse in the care of a stable client with a closed head injury who is 1 day post-craniotomy. The practical nurse prepares to administer the 7:00 AM medications and reviews the client’s medication administration record. Which prescription prompts the practical nurse to contact the prescribing health care provider for clarification?
- A. Acetaminophen 1,000 mg IV, every 6 hours
- B. Gabapentin 300 mg orally, every 8 hours
- C. Hydrocodone/acetaminophen (5 mg/325 mg) orally, every 4 hours PRN
- D. Phenytoin 100 mg orally, every 12 hours
Correct Answer: A
Rationale: Acetaminophen 1,000 mg IV is unusual for routine post-craniotomy pain and risks overdose if combined with oral hydrocodone/acetaminophen, requiring clarification. Other medications are standard.