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 caring for a 10-year-old client with osteomyelitis. Which of the following actions should the nurse take to promote age-appropriate growth and development during hospitalization?
- A. Ask the parent to bring schoolwork for the client to complete
- B. Encourage the client to engage in imaginary play with animal puppets
- C. Explain procedures to the client immediately before they are performed
- D. Provide opportunities for the client to play independently
Correct Answer: A
Rationale: Schoolwork supports cognitive development for a 10-year-old. Imaginary play suits younger children, last-minute explanations increase anxiety, and independent play may not meet social needs.
The practical nurse is collaborating with the registered nurse to develop a care plan for a homeless client just brought into the emergency department with frostbite to the fingers and toes. The client is experiencing numbness, and assessment shows mottled skin. Which interventions should be included in the client's plan of care? Select all that apply.
- A. Apply occlusive dressings after rewarming
- B. Elevate affected extremities after rewarming
- C. Massage the areas to increase circulation
- D. Provide adequate analgesia
- E. Provide continuous warm water soaks
Correct Answer: B,D
Rationale: Elevation reduces swelling post-rewarming. Analgesia manages pain. Occlusive dressings trap moisture, massaging risks tissue damage, and continuous soaks may cause maceration.
A home health nurse is managing care for an adolescent client with cystic fibrosis. Which of the following potential complications should the nurse consider when developing a nursing care plan? Select all that apply.
- A. Chronic hypoxemia
- B. Diabetes insipidus
- C. Frequent respiratory infections
- D. Obesity
- E. Vitamin deficiencies
Correct Answer: A,C,E
Rationale: Cystic fibrosis causes chronic hypoxemia , frequent infections , and vitamin deficiencies due to malabsorption. Diabetes insipidus is unrelated, and obesity is unlikely due to high metabolic demand.
A client with generalized anxiety disorder has received a new prescription for sertraline. The nurse should reinforce teaching to the client on what possible adverse effect?
- A. Hypernatremia
- B. Sexual dysfunction
- C. Urinary retention
- D. Weight loss
Correct Answer: B
Rationale: Sertraline commonly causes sexual dysfunction, a significant side effect. Hypernatremia , urinary retention , and weight loss are less common.
The nurse is caring for a client who does not speak English. Which of the following actions should the nurse take to facilitate communication with the client? Select all that apply.
- A. Allow the client's spouse to act as the interpreter.
- B. Use short sentences when speaking to the interpreter.
- C. Ask if the client has a gender preference for the interpreter.
- D. Speak directly to the interpreter when providing information.
- E. Ensure the client understands the information provided via the interpreter.
Correct Answer: B,C,E
Rationale: Short sentences aid clarity. Gender preference respects cultural needs. Ensuring understanding confirms effective communication. Using a spouse risks bias, and speaking to the interpreter excludes the client.