Nokea
The nurse is discussing nutritional requirements with the parents of an 18 month-old child. Which of these statements about milk consumption is correct?
- A. May drink as much milk as desired
- B. Can have milk mixed with other foods
- C. Will benefit from fat-free cow's milk
- D. Should be limited to 3-4 cups of milk daily
Correct Answer: D
Rationale: Should be limited to 3-4 cups of milk daily. Excessive milk intake can reduce consumption of other nutrients.
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The nurse on postpartum is preparing four clients for discharge. It would be MOST important for the nurse to refer which of the following clients for homecare?
- A. A 15-year-old who vaginally delivered a 7-lb male two days ago.
- B. An 18-year-old multipara who delivered a 9-lb female by cesarean section two days ago.
- C. A 20-year-old multipara who delivered 1 day ago and is complaining of cramping.
- D. A 22-year-old who delivered by cesarean section and is complaining of burning on urination.
Correct Answer: D
Rationale: Burning on urination suggests a urinary tract infection, requiring homecare follow-up. Options A, B, and C are routine postpartum findings.
The nurse is caring for a client with a history of seizures who is receiving phenytoin (Dilantin) 100 mg PO tid. Which of the following client statements would be of GREATest concern to the nurse?
- A. I brush my teeth twice a day.
- B. I take my medication with milk.
- C. I have a rash on my arms.
- D. I feel drowsy in the morning.
Correct Answer: C
Rationale: A rash may indicate a hypersensitivity reaction to phenytoin, potentially progressing to severe conditions like Stevens-Johnson syndrome, requiring immediate evaluation. Options A, B, and D are less concerning: brushing teeth is routine, milk does not affect absorption, and drowsiness is a common side effect.
The nurse is planning discharge for a client who suffered a mild myocardial infarction (MI) and smokes one pack of cigarettes per day.
Which of the following recommendations by the nurse would be BEST?
- A. Participation in a program such as 'Nicotine Avoidance.'
- B. Avoidance of aerobic physical activity.
- C. Instillation of a humidifier in the home heating system.
- D. Strict adherence to a low-calorie, low-sodium, high-lipid diet.
Correct Answer: A
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-smoking is definitely a modifiable risk factor, self-help program can significantly aid in quitting (2) well-planned aerobic physical activity program is a must (3) humidification does not modify the risk factors (4) low-calorie is appropriate, needs a low-fat, not a high-fat, diet
The nurse discovers that a hospitalized client is not breathing and has no pulse. After calling for help, what should the nurse do next?
- A. Give the client two breaths
- B. Administer five chest compressions
- C. Go get the emergency cart
- D. Defibrillate the client
Correct Answer: A
Rationale: Per CPR guidelines, after calling for help, provide two rescue breaths if trained, followed by compressions. Fetching the cart or defibrillating delays resuscitation.
A school-aged child informs the school nurse that his right knee 'doesn't feel right.' Which of the following actions should the nurse take FIRST?
- A. Instruct the child to extend the right leg.
- B. Put both of the child's legs through range-of-motion.
- C. Advise the child to soak the right knee in warm water.
- D. Compare the appearance of the right knee with the left knee.
Correct Answer: D
Rationale: Comparing knees assesses for swelling or deformity, the first step in physical assessment. Options A, B, and C risk exacerbating injury or are interventions before assessment.