Nokea
The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main source of fluids for an infant until about 12 months of age?
- A. Formula or breast milk
- B. Dilute nonfat dry milk
- C. Warmed fruit juice
- D. Fluoridated tap water
Correct Answer: A
Rationale: Formula or breast milk. Formula or breast milk are the perfect food and source of nutrients and liquids up to 1 year of age.
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The charge nurse is observing nursing staff. In which activity illustrated should the charge nurse intervene because it places the nurse most at risk for back injury?
- A. intervene_1.PNG
- B. intervene_2.PNG
- C. intervene_3.PNG
- D. intervene_4.PNG
Correct Answer: D
Rationale: Bending and twisting the torso, as described in option D, poses the highest risk for back injury due to improper body mechanics, even with a transfer belt. The client's potential to grab the nurse's shoulder or arm increases the risk by destabilizing the nurse's stance.
Which of these actions should the nurse perform first when a client is admitted with a diagnosis of C-difficile?
- A. Initiate contact precautions
- B. Administer prescribed antibiotics
- C. Obtain a stool culture
- D. Educate the client about hand hygiene
Correct Answer: A
Rationale: Initiating contact precautions is the first step to prevent the spread of C-difficile, which is highly contagious through contact with contaminated surfaces or feces.
Which of these actions by the nurse best prevents medication errors when administering medications to a client?
- A. Checking the client's wristband before giving medications
- B. Using two forms of client identification before administering medication
- C. Administering medications at the exact time they are ordered
- D. Verifying the medication order with another nurse
Correct Answer: B
Rationale: Using two forms of client identification (e.g., name and medical record number) is the best practice to prevent medication errors by ensuring the right client receives the medication.
A nurse taking a patient's history realizes the patient is complaining of SOB and weakness in the lower extremities. The patient has a history of hyperlipidemia, and hypertension. Which of the following may be occurring?
- A. The patient is developing CHF
- B. The patient may be having a MI
- C. The patient may be developing COPD
- D. The patient may be having an onset of PVD
Correct Answer: B
Rationale: Myocardial infarction may be associated with SOB and muscle weakness.
Hearing screening of prematurely born infants is an effective means of identifying disease and is an example of:
- A. primary prevention.
- B. secondary prevention.
- C. tertiary prevention.
- D. disability prevention.
Correct Answer: B
Rationale: The three levels of prevention address disease and disability across all phases, from absence of disease and at risk for disease, to preventing further impairment. Hearing impairment associated with prematurity cannot be prevented by screening, but identifying the infants with hearing loss might prevent sequelae and further impairment by allowing early intervention.