To maintain Bryant's traction, the nurse must make certain that the child's:
- A. Hips are resting on the bed with the legs suspended at a right angle to the bed
- B. Hips are slightly elevated above the bed with the legs suspended at a right angle to the bed
- C. Hips are elevated above the level of the body on a pillow with the legs suspended parallel to the bed
- D. Hips and legs are flat on the bed with the traction positioned at the foot of the bed
Correct Answer: B
Rationale: Bryant's traction requires hips slightly elevated and legs at a right angle to the bed to align the femur properly and reduce pressure on the pelvis.
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A nurse discovers a cyanotic newborn with excessive frothy mucus in the mouth. What should be the nurse’s first action?
- A. Administer 100% oxygen
- B. Auscultate the lungs
- C. Place infant in knee-chest position
- D. Suction the infant’s mouth
Correct Answer: D
Rationale: Suctioning the mouth (D) clears mucus, addressing potential airway obstruction causing cyanosis. Oxygen (A), auscultation (B), and positioning (C) are secondary until the airway is clear.
Which meal should the nurse recommend for a client at 13 weeks gestation?
- A. Baked chicken, turnip greens, peanut butter cookie, and grape juice
- B. Baked swordfish, fries, baked apples, and fat-free milk
- C. Chilled ham and cheese sandwich, broccoli, orange slices, and water
- D. Fried liver and onions, pasteurized cheese squares, fresh fruit cup, and water
Correct Answer: A
Rationale: Baked chicken, greens, cookie, and juice (A) provide balanced nutrients without high-mercury fish (B), deli meats (C), or undercooked liver (D), which pose risks in pregnancy.
The nurse has reinforced teaching with the parent of a 3-year-old client who has acute diarrhea. Which of the following statements by the parent would require follow-up?
- A. I will apply a skin barrier cream to my child’s diaper area until the diarrhea subsides.
- B. I will encourage my child to drink small amounts of fluids at frequent intervals.
- C. I will feed my child a diet of bananas, rice, applesauce, and toast for the next few days.
- D. I will return to the clinic if I notice a decrease in my child’s urine output.
Correct Answer: C
Rationale: The BRAT diet (C) is outdated and may lack nutrients, risking prolonged recovery. Skin barrier cream (A), frequent fluids (B), and monitoring urine output (D) are appropriate for preventing skin breakdown, dehydration, and detecting complications.
When teaching parents about sickle cell disease, the nurse should tell them that their child's anemia is caused by
- A. Reduced oxygen capacity of cells due to lack of iron
- B. An imbalance between red cell destruction and production
- C. Depression of red and white cells and platelets
- D. Inability of sickle shaped cells to regenerate
Correct Answer: B
Rationale: An imbalance between red cell destruction and production. Anemia results when the rate of red cell destruction exceeds the rate of production through stimulated erythropoiesis in bone marrow (red cell life span shortened from 120 days to 12-20 days).
The nurse has reinforced teaching about formula preparation with the parent of a newborn. Which of the following statements by the parent would indicate a correct understanding of the teaching? Select all that apply.
- A. I should avoid using the microwave to heat my baby's formula.
- B. I must wash the top of the concentrated formula can before opening it.
- C. If my baby is feeding poorly, I should use less water to dilute the formula.
- D. Prepared formula should be kept in the refrigerator and discarded after 24 hours.
- E. Bottled water does not need to be boiled when used to reconstitute powdered formula.
Correct Answer: A,B,D
Rationale: Microwaving (A) can cause uneven heating, risking burns, so it’s avoided. Washing the can top (B) prevents contamination. Refrigerated formula must be discarded after 24 hours (D) to prevent bacterial growth. Diluting less (C) alters nutrition, and bottled water (E) may need boiling depending on safety, indicating incorrect understanding.
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