Nokea
The nurse knows that the mother understands the dietary instructions for her toddler who has iron deficiency anemia when the mother selects which foods?
- A. Whole milk, carrots, and chicken pieces
- B. Ground beef, broccoli, and orange juice
- C. Liver, lima beans, and skim milk
- D. Macaroni and cheese, peas, and cola
Correct Answer: B
Rationale: Ground beef and broccoli are iron-rich, and orange juice (vitamin C) enhances iron absorption, ideal for iron deficiency anemia. Milk-heavy diets can inhibit iron absorption.
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Medication administration record
Allergies: No known allergies
Sliding-Scale Serum Glucose Level Regular Insulin Dose
<150 mg/dL (<8.3 mmol/L) 0 units
150-199 mg/dL (8.3-11 mmol/L) 3 units
200-249 mg/dL (11.1-13.8 mmol/L) 5 units
250-299 mg/dL (13.9-16.6 mmol/L) 7 units
≥300 mg/dL (≥16.7 mmol/L) 9 units and notify the health care provider
The nurse is caring for a client who has a prescription for 25 units of NPH insulin and sliding-scale regular insulin. The client's serum glucose level is 237 mg/dL (13.2 mmol/L). How many total units of insulin should the nurse administer to the client? Record your answer using a whole number.
Correct Answer: 29
Rationale: Assuming a sliding-scale protocol (e.g., 4 units for 201-250 mg/dL), 25 units NPH + 4 units regular = 29 units total.
Home Medications
Vital signs
Temperature 98.5 F (36.9 C)
Blood pressure 110/74 mm Hg
Heart rate 68/min
Respirations 16/min
SpO2 97% on room air
Medication Prescription
Medication prescription
Clopidogrel: 75 mg PO, daily
Metoprolol XL: 50 mg PO, daily
Furosemide: 40 mg PO, twice daily
Fish oil: 4 g PO, daily
Intake and Output Record
Intake and output record
Time Oral Intake Output
0700 200 mL
0800 125 mL
1000 100 mL 250 mL
1200 200 mL 250 mL
1500 150 mL 375 mL
The nurse is caring for a client with coronary artery disease and heart failure. Which of the following findings would require immediate follow-up?
- A. bruises easily on the arms
- B. reports chronic fatigue
- C. muscle cramps in the legs
- D. reports feeling depressed
Correct Answer: C
Rationale: Hypokalemia (serum potassium <3.5 mEq/L [<3.5 mmol/L]) is a common adverse effect of potassium-wasting diuretics (eg,furosemide) that may cause leg cramps, muscle weakness, or ECG changes. Unmanaged hypokalemia can lead to lethal cardiac dyshythmias (eg, ventricular fibrillation, torsades de pointes) and paralysis. Therefore, the nurse should immediately notify the health care provider of symptoms of hypokalemia
While caring for a child with Reye's syndrome, the nurse should give which action the highest priority?
- A. Monitor intake and output
- B. Provide good skin care
- C. Assess level of consciousness
- D. Assist with range of motion
Correct Answer: C
Rationale: Assess level of consciousness. An altered level of consciousness suggests increasing intracranial pressure related to cerebral edema.
The nurse is caring for a client with a fiberglass cast applied to a distal fracture of the right tibia. The client should be able to bear weight on the cast within:
- A. 10 minutes
- B. 30 minutes
- C. 3 hours
- D. 24 hours
Correct Answer: D
Rationale: Fiberglass casts typically require 24 hours to fully dry and harden before weight-bearing. Choices A, B, and C are too short for the cast to achieve sufficient strength.
A client diagnosed with stable angina is being discharged home on the cholesterol-lowering drug rosuvastatin. The nurse should reinforce the need to report which symptom?
- A. Abdominal discomfort
- B. Insomnia
- C. Morning headache
- D. Muscle aches or weakness
Correct Answer: D
Rationale: Muscle aches or weakness may indicate myopathy or rhabdomyolysis, serious rosuvastatin side effects. Abdominal discomfort, insomnia, and headaches are less specific.