Nokea
The nurse is reviewing a nutritional plan for a 6-month-old who has recently been started on solid foods. Which of the following recommendations has the highest priority in the plan?
- A. Canned baby food is more expensive than food prepared at home
- B. Finger foods can be introduced before the child has teeth
- C. New foods should be introduced at least 5-7 days apart
- D. Rice cereal can be mixed with cow's milk to increase nutritional intake
Correct Answer: C
Rationale: Introducing new foods 5-7 days apart (C) prevents allergic reactions by identifying triggers, making it the priority. Cost (A), finger foods (B), and cow's milk (D, not recommended before 12 months) are secondary.
You may also like to solve these questions
A woman is pregnant for the first time and is Rh negative. Her husband is Rh positive. She tells the nurse that he is very worried about her baby. Which information should the nurse plan to include when talking with this woman?
- A. The first baby should not be affected.
- B. She will need to get treatment after the second baby is born.
- C. There is nothing that can be done to prevent the baby from developing erythroblastosis fetalis, but it can be treated.
- D. She can have intrauterine transfusion for the first baby if blood levels indicate that the child is affected.
Correct Answer: A
Rationale: The first Rh-positive baby is typically unaffected as maternal antibodies develop post-delivery. RhoGAM is given after birth to prevent issues in future pregnancies, not after the second baby.
An ambulatory client reports edema during the day in his feet and ankles that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask?
- A. Have you had a recent heart attack?
- B. Do you become short of breath during your normal daily activities?
- C. How many pillows do you use at night to sleep comfortably?
- D. Do you smoke?
Correct Answer: B
Rationale: Do you become short of breath during your normal daily activities? This assesses for activity intolerance, a symptom of right-sided heart failure causing edema.
A 78-year-old client is admitted following a cerebrovascular accident. He cannot move his left arm and leg. Which finding would indicate to the nurse that the client also has homonymous hemianopia?
- A. The client has difficulty moving his right arm.
- B. The client did not notice a nurse who was standing on his left side.
- C. The client is having difficulty swallowing.
- D. The client is having difficulty speaking.
Correct Answer: B
Rationale: Homonymous hemianopia, a visual field defect from right brain stroke, causes left-sided vision loss, so the client misses the nurse on the left, unlike arm movement, swallowing, or speech issues.
The nurse receives the handoff of care report on four clients. Which client should the nurse see first?
- A. Client reporting incisional pain of 8 on a scale of 0-10 with a respiratory rate of 25/min who had a right pneumonectomy 12 hours ago
- B. Client with a left pleural effusion who has crackles, absent breath sounds in the left base, and an SpO2 of 94% on room air
- C. Client with a temperature of 100.4 F (38 C) and a respiratory rate of 12/min who had a small bowel resection 1 day ago
- D. Client with pneumonia who has a temperature of 97.6 F (36.4 C), has an SpO2 of 93% on 4 L/min supplemental oxygen, and is becoming restless
Correct Answer: D
Rationale: Restlessness in a pneumonia client with low SpO2 (D) suggests worsening hypoxia, requiring immediate assessment. Severe pain (A) is urgent but stable. Pleural effusion (B) and fever (C) are less critical.
A client with coronary artery disease was discharged home with a prescription for sublingual nitroglycerin to treat angina. Which statement by the client indicates that further teaching is required?
- A. I may experience flushing but will continue to take the medication as prescribed.
- B. I should lie down before taking the medication.
- C. I should not swallow the tablet.
- D. I will wait to call 911 if I don't experience relief after the third tablet.
Correct Answer: D
Rationale: Delaying 911 after three doses (D) is dangerous; clients should call after no relief from the first dose or after three doses (5 minutes apart). Flushing (A), lying down (B), and not swallowing (C) are correct.