Nokea
The nurse is teaching the mother of a child with attention deficit disorder regarding the use of Ritalin (methylphenidate). The nurse recognizes that the mother understands her teaching when she states the importance of:
- A. Offering high-calorie snacks
- B. Watching for signs of infection
- C. Observing for signs of oversedation
- D. Using a sunscreen with an SPF of 30
Correct Answer: C
Rationale: Ritalin, a stimulant, can cause side effects like insomnia or agitation, not oversedation. The mother's mention of oversedation indicates a misunderstanding, but the question implies correct teaching, so observing for side effects like overstimulation is key.
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The nurse is preparing to administer a feeding via a nasogastric tube. The nurse would perform which of the following before initiating the feeding?
- A. Assess for tube placement by aspirating stomach content
- B. Place the patient in a left-lying position
- C. Administer feeding with 50% Dextrose
- D. Ensure that the feeding solution has been warmed in a microwave for 2 minutes
Correct Answer: A
Rationale: Aspirating stomach content confirms nasogastric tube placement, preventing aspiration.
The nurse has an order to give 500 mL of 0.45% NS over 12 hours. The IV set has a drop factor of 10. How many gtts/min should the client receive? Fill in the blank.
Correct Answer: 7
Rationale: Rate = 500 mL ÷ 12 hr = 41.67 mL/hr. Drops/min = (41.67 mL/hr × 10 gtts/mL) ÷ 60 min = 6.94 gtts/min, rounded to 7 gtts/min.
The client is receiving total parenteral nutrition (TPN). Which lab test should be evaluated while the client is receiving TPN?
- A. Hemoglobin
- B. Creatinine
- C. Blood glucose
- D. White blood cell count
Correct Answer: C
Rationale: TPN's high dextrose content requires glucose monitoring to prevent hyperglycemia.
A client with a history of phenylketonuria is seen at the local family planning clinic. After completing the client's intake history, the nurse provides literature for a healthy pregnancy. Which statement indicates that the client needs further teaching?
- A. I can help control my weight by switching from sugar to Nutrasweet.
- B. I need to resume my old diet before becoming pregnant.
- C. Fresh fruits and raw vegetables will make excellent betweenmeal snacks.
- D. I need to eliminate most sources of phenylalanine from my diet.
Correct Answer: A
Rationale: Nutrasweet (aspartame) contains phenylalanine, which must be avoided in phenylketonuria, indicating a need for further teaching.
All of the following are examples of secondary disease prevention EXCEPT
- A. leading a support group for people who suffer from depression.
- B. mammogram screenings.
- C. testing and treatment of babies born to mothers with syphilis.
- D. developing a daily exercise program to prevent a second MI.
Correct Answer: A
Rationale: Secondary prevention detects/treats disease early (mammograms, syphilis testing, exercise post-MI). Support groups (A) are tertiary, aiding coping with existing disease.