Nokea
The nurse is teaching parents of a newborn about feeding their infant. Which of the following instructions should the nurse include?
- A. Use the defrost setting on microwave ovens to warm bottles.
- B. When refrigerating formula, don't feed the baby partially used bottles after 24 hours.
- C. When using formula concentrate, mix two parts water and one part concentrate.
- D. If a portion of one bottle is left for the next feeding, go ahead and add new formula to fill it.
Correct Answer: A
Rationale: Parents must be careful when warming bottles in a microwave oven because the milk can become superheated. When a microwave oven is used, the defrost setting should be chosen, and the temperature of the formula should be checked before giving it to the baby. Refrigerated, partially used bottles should be discarded after 4 hours because the baby might have introduced some pathogens into the formula. Returning the bottle to the refrigerator does not destroy pathogens. Formula concentrate and water are usually mixed in a 1:1 ratio of one part concentrate and one part water. Infants should be offered fresh formula at each feeding. Partially used bottles should not have fresh formula added to them. Pathogens can grow in partially used bottles of formula and be transferred to the new formula.
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The LPN on shift notices a client come in to the clinic with bruises on his arm. The client seems very afraid and doesn't speak much which concerns the nurse because these are signs of physical abuse. The nurse should
- A. use therapeutic communication to talk to the client and attempt to get evidence of suspected abuse
- B. report the findings to the appropriate authorities based on the state requirements and protocols
- C. ignore the bruises, as this is not why the client is being treated and is not appropriate for the nurse to address
- D. report the suspected abuse to one of the other nurses and work together on how to handle it
Correct Answer: B
Rationale: It is the responsibility of any healthcare provider/team member to report any type of suspected abuse to the police or dictated agency per the state policy.
Rehabilitation services begin:
- A. when the client enters the health care system.
- B. after the client requests rehabilitation services.
- C. after the client's physical condition stabilizes.
- D. when the client is discharged from the hospital.
Correct Answer: A
Rationale: Rehabilitation services should begin when the client enters the health care system.
The nursing staff has a normal nurse-to-client ratio of three clients per nurse on the floor. Nurse Ann tells nurse Christine that one of her client's status is declining but that she will do her best to juggle her other two clients. Which action is most appropriate?
- A. Nurse Christine should offer to give medications to nurse Ann's other two clients.
- B. Nurse Christine should inform their supervisor that assignments may need to be changed.
- C. Nurse Christine should ask the other nurses who might be able to help nurse Ann.
- D. Nurse Ann should try not to burden the other nurses and continue caring for her assigned clients.
Correct Answer: B
Rationale: When there is a change in the client's status, the supervisor should be made aware so that client care assignments can be changed as needed.
The nurse is caring for a client who has just tested positive for HIV. The client asks the nurse not to tell anyone outside of the care team about his diagnosis. What response is most appropriate?
- A. I have to inform all clients on the unit of your diagnosis as it is transmissible.'
- B. I will not communicate your diagnosis to anyone without your permission.'
- C. Because this is a communicable disease, it may need to be reported to the CDC.'
- D. You should not be concerned with who I share your diagnosis with.'
Correct Answer: C
Rationale: Many communicable diseases, such as HIV, have surveillance programs that require mandatory reporting.
An assessment of the skull of a normal 10-month-old baby should identify which of the following?
- A. closure of the posterior fontanel.
- B. closure of the anterior fontanel.
- C. overlap of cranial bones.
- D. ossification of the sutures.
Correct Answer: A
Rationale: The posterior fontanel should close by the age of 2 months.