Nokea
The nurse is observing the parent feed a 3-month-old diagnosed with gastroesophageal reflux. Which action by the parent indicates that further teaching is necessary?
- A. The parent does not push the infant to finish the bottle
- B. The parent engages the infant in active play after the feeding
- C. The parent interrupts the feeding to burp the infant
- D. The parent supports the infant upright during the feeding
Correct Answer: B
Rationale: Active play post-feeding can worsen reflux. Not forcing the bottle , burping , and upright positioning are appropriate.
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The nurse is reviewing new orders for a client with chronic kidney disease. The nurse should clarify the order for
- A. dietary sodium restriction
- B. magnesium hydroxide
- C. fluid restriction
- D. furosemide
Correct Answer: B
Rationale: Magnesium hydroxide risks toxicity in CKD due to impaired excretion. Sodium restriction , fluid restriction , and furosemide are appropriate.
An adult is admitted with a pneumothorax following an accident. Immediately after insertion of a chest tube, the client says to the nurse, 'Why do I have a tube in my chest and that thing hanging on the side of the bed? I don't like it.' What should the nurse include when replying to the client?
- A. Tell the client that the chest tube helps the client take bigger breaths
- B. Focus on the client's feelings
- C. Explain that the chest tube will remove air and/or fluid from the pleural cavity and allow the lung to reexpand
- D. Tell the client that the nurse will contact the physician to have it removed
Correct Answer: C
Rationale: The chest tube drains air/fluid from the pleural space, allowing lung re-expansion in pneumothorax, providing an accurate, educational response to the client's question.
When caring for a client with advanced cirrhosis of the liver, which nursing diagnosis should take priority?
- A. Risk for injury: hemorrhage
- B. Risk for injury related to peripheral neuropathy
- C. Altered nutrition: less than body requirements
- D. Fluid volume excess: ascites
Correct Answer: A
Rationale: Risk for injury: hemorrhage. Liver disease interferes with the production of prothrombin and other factors essential for blood clotting. Hemorrhage, especially from esophageal varices, can be life-threatening.
A client is prescribed warfarin sodium (Coumadin) to be continued at home. Which focus is critical to be included in the nurse's discharge instruction?
- A. Maintain a consistent intake of green leafy foods
- B. Report any nose or gum bleeds
- C. Take Tylenol for minor pains
- D. Use a soft toothbrush
Correct Answer: B
Rationale: Report any nose or gum bleeds. The client should notify the health care provider if blood is noted in stools or urine, or any other signs of bleeding occur.
The nurse is caring for a client with community acquired pneumonia. When collecting client data, the nurse should anticipate which findings? Select all that apply.
- A. Crackles
- B. High-pitched wheezing
- C. Hyperresonance
- D. Pleural chest pain
- E. Productive cough
Correct Answer: A,D,E
Rationale: Crackles , pleural pain , and productive cough are typical in pneumonia. Wheezing suggests asthma, and hyperresonance indicates air trapping.