Nokea
The nurse knows that a client understands a low residue diet when he selects which of the following from the menu?
- A. Rice and lean chicken
- B. Pasta with vegetables
- C. Strawberry pie
- D. Tuna casserole
Correct Answer: A
Rationale: A low residue diet is designed to minimize the amount of undigested food in the stool, therefore reducing the frequency and volume of bowel movements. Foods high in fiber, such as pasta with vegetables and strawberry pie, may not be suitable for a low residue diet as they can increase stool bulk. Tuna casserole may contain ingredients like bread crumbs or high-fiber vegetables that are also not recommended on a low residue diet. Rice and lean chicken are good choices for this diet as they are low in fiber and easy to digest, making them suitable options for a client following a low residue diet.
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The nurse is conducting discharge teaching about signs and symptoms of heart failure to parents of an infant with a repaired tetralogy of Fallot. Which signs and symptoms should the nurse include? (Select all that apply.)
- A. Warm flushed extremities
- B. Weight loss
- C. Decreased urinary output
- D. Sweating (inappropriate)
Correct Answer: C
Rationale: C. Decreased urinary output: This can be a sign of fluid retention, which is a common symptom of heart failure. Infants with heart failure may have decreased urine output as the body tries to retain fluid to help compensate for the heart's decreased ability to pump effectively.
During thoracentesis, which of the following nursing intervention will be most crucial?
- A. Place patient in a quiet and cool room
- B. Maintain strict aseptic technique
- C. Advice patient to sit perfectly still during needle insertion until it has been withdrawn from the chest
- D. Apply pressure over the puncture site as soon as the needle is withdrawn
Correct Answer: B
Rationale: Maintaining strict aseptic technique during thoracentesis is the most crucial nursing intervention. Thoracentesis is a procedure where a needle is inserted into the pleural space to obtain a sample of fluid for diagnostic purposes or to drain excess fluid for therapeutic relief. It is essential to prevent the introduction of pathogens or contaminants into the pleural space, as this can lead to serious complications such as infection. By following strict aseptic technique, the risk of complications can be minimized, ensuring the safety and well-being of the patient undergoing the procedure.
minutes after birth the normal heart rate of the infant may range between:
- A. 100 and 180
- B. 130 and 170
- C. 120 and 160
- D. 100 and 130
Correct Answer: C
Rationale: The normal heart rate of a newborn infant is typically between 120 and 160 beats per minute within the first minutes after birth. This range is considered normal for a healthy newborn and reflects the development of the infant's cardiovascular system. It is important to monitor the newborn's heart rate closely in the immediate post-birth period to ensure that it remains within this normal range. Any deviations from this range may indicate a need for further evaluation and intervention.
A 2-year-old male child has an asymptomatic right flank mass discovered incidentally by the mother while bathing. Suspicion of Wilms tumor is raised. Of the following, the LEAST likely investigation to be performed in this child is
- A. plain abdominal radiography
- B. computerized tomography (CT) scan of the abdomen
- C. CT scan of the chest
- D. biopsy of the mass
Correct Answer: D
Rationale: Biopsy is generally avoided in suspected Wilms tumor to prevent upstaging the disease.
A preterm newborn, after spending 8 weeks in the NICU, is being discharged. The parents of the newborn express apprehension and worry that the newborn may still be in danger. How should the nurse interpret these statements?
- A. Normal
- B. A reason to postpone discharge
- C. Suggestive of maladaptation
- D. Suggestive of inadequate bonding
Correct Answer: A
Rationale: It is normal for parents of preterm newborns who have spent time in the NICU to express apprehension and worry upon discharge. The NICU experience can be stressful and overwhelming for families, and it is common for parents to feel anxious about taking their newborn home. The nurse should provide support and education to help alleviate the parents' concerns and ensure a smooth transition from the hospital to home. It is important to acknowledge the parents' feelings, offer reassurance, and reinforce the importance of follow-up care and monitoring.