Nokea
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.
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A nurse is teaching the parent of a nine month-old infant about diaper dermatitis. Which of the following measures would be appropriate for the nurse to include?
- A. Use only cloth diapers that are rinsed in bleach
- B. Do not use occlusive ointments on the rash
- C. Use commercial baby wipes with each diaper change
- D. Discontinue a new food that was added to the infant's diet just prior to the rash
Correct Answer: D
Rationale: Discontinue a new food that was added to the infant's diet just prior to the rash. New foods can be a cause of diaper dermatitis.
Laboratory reference ranges
BUN
10-20 mg/dL
(3.6-7.1 mmol/L)
An 80-year-old client is receiving amikacin, an aminoglycoside antibiotic, IVPB every 12 hours. Which of the following data obtained
by the practical nurse is most important to report to the registered nurse before the client receives the next dose?
- A. client reports tinnitus
- B. Blood pressure 104/60 mm Hg
- C. urine output of 400 mL since last dose
Correct Answer: A
Rationale: Tinnitus may indicate ototoxicity, requiring immediate reporting. Low BP and urine output are less urgent without context of medication.
Joan is at lunch in the hospital cafeteria with a nurse coworker. Joan is very allergic to nuts and always carries her anaphylactic kit with her. Joan tells her coworker that there must have been nuts in something she ate because she is having increasing difficulty breathing. What should the nurse do immediately?
- A. Take her to the hospital emergency room
- B. Administer the medication in her friend's anaphylactic kit
- C. Call the floor for help
- D. Monitor the symptoms
Correct Answer: B
Rationale: Administering the anaphylactic kit medication (epinephrine) is the immediate action to reverse anaphylaxis, prioritizing airway patency.
The clinic nurse is interviewing the parents of a 6-month-old client about the infant's diet. Which statement by the parents is most concerning?
- A. Because apples are healthy, we make apple pie and feed small, soft bites to our baby.
- B. If our baby refuses to finish foods, we continue to offer small bites, so food isn't wasted.
- C. Infant oatmeal sweetened with fresh honey is our baby's favorite breakfast.
- D. We found that the food in TV dinners can be easily pureed and is convenient.
Correct Answer: C
Rationale: Honey poses a botulism risk in infants under 1 year, making it the most concerning. Apple pie and TV dinners are inappropriate but less dangerous, and offering bites is not harmful.
Lab results indicate that the client's serum aminophylline level is 17 mcg/mL. The nurse recognizes that the aminophylline level is:
- A. Within therapeutic range
- B. Too high and should be reported
- C. Questionable and should be repeated
- D. Too low to be therapeutic
Correct Answer: A
Rationale: The therapeutic range for aminophylline is typically 10-20 mcg/mL. A level of 17 mcg/mL is within this range, so no action is needed. Answer B is incorrect as the level is not too high. Answer C is unnecessary as the level is clearly therapeutic. Answer D is incorrect as the level is not too low.