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When providing discharge teaching for a group of clients, a nurse should recommend a referral to a dietitian for which client?
- A. A client who has a prescription for warfarin and states, 'I will need to limit how much spinach I eat.'
- B. A client who has gout and states, 'I can continue to eat anchovies on my pizza.'
- C. A client who has a prescription for spironolactone and states, 'I will reduce my intake of foods that contain potassium.'
- D. A client who has osteoporosis and states, 'I'll plan to take my calcium carbonate with a full glass of water.'
Correct Answer: B
Rationale: The correct answer is the client who has gout and states, 'I can continue to eat anchovies on my pizza.' Gout is a condition that requires dietary modifications to manage symptoms. Anchovies are high in purines, which can exacerbate gout symptoms. Therefore, a referral to a dietitian is essential to provide appropriate dietary guidance for a client with gout. Clients on warfarin may need to monitor their vitamin K intake, particularly from foods like spinach. Clients taking spironolactone should be cautious about potassium-rich foods. Clients with osteoporosis should be educated on the proper administration of calcium supplements but do not necessarily need a dietitian referral for this specific statement.
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A healthcare professional is preparing to assess a 2-week-old newborn. Which of the following actions should the professional plan to take?
- A. Obtain the newborn's body temperature using a tympanic thermometer.
- B. FACES pain scale.
- C. Auscultate the newborn's apical pulse for 60 seconds.
- D. Measure the newborn's head circumference over the eyebrows and below the occipital prominence.
Correct Answer: C
Rationale: Assessing the apical pulse in newborns is important to evaluate their cardiac function. The normal heart rate for a newborn is typically between 100-160 beats per minute. Auscultating the apical pulse for a full 60 seconds allows for an accurate assessment of the newborn's heart rate. This is a crucial component of the newborn assessment to ensure the baby's cardiovascular system is functioning within the expected range.
A healthcare professional is preparing to administer an autologous blood product to a client. Which of the following actions should the professional take to identify the client?
- A. Match the client's blood type with the type and cross-match specimens
- B. Confirm the provider's prescription matches the number on the blood component
- C. Ask the client to state their blood type and the date of their last blood donation
- D. Ensure that the client's identification band matches the number on the blood unit
Correct Answer: A
Rationale: When preparing to administer an autologous blood product, it is crucial to correctly identify the client to prevent errors. Matching the client's blood type with the type and cross-match specimens ensures that the blood product is intended for the correct recipient. This step helps in verifying the patient's identity and avoiding any transfusion-related complications. Confirming the blood type through type and cross-matching is a standard practice to ensure patient safety during blood transfusions.
A client has chronic pancreatitis. Which of the following dietary recommendations should be made?
- A. Coffee with creamer
- B. Lettuce with sliced avocados
- C. Broiled skinless chicken breast with brown rice
- D. None of the above
Correct Answer: C
Rationale: Chronic pancreatitis requires a low-fat diet to reduce stress on the pancreas. Broiled skinless chicken breast with brown rice is a suitable option as it is low in fat. Coffee with creamer and lettuce with sliced avocados are not recommended for individuals with chronic pancreatitis due to their fat content. Choosing options high in fat can exacerbate symptoms and increase the workload on the pancreas, worsening the condition.
A healthcare professional is preparing to measure an infant's temperature. Which of the following actions should the healthcare professional take?
- A. Place the tip of the thermometer under the center of the infant's axilla
- B. Pull the pinna of the infant's ear forward before inserting the probe
- C. Insert the probe 3.8 cm (1.5in) into the infant's rectum
- D. Insert the thermometer in front of the infant's tongue
Correct Answer: A
Rationale: When measuring an infant's temperature, the most appropriate and non-invasive method is to place the tip of the thermometer under the center of the infant's axilla (armpit). This method is safe, quick, and comfortable for the infant. Inserting the probe into the rectum is invasive and not recommended for routine temperature measurement in infants. Inserting the thermometer in front of the infant's tongue is not a reliable method for measuring temperature. Pulling the pinna of the ear forward is a technique used for adults, not infants.
A healthcare professional realizes that the wrong medication has been administered to a client. Which of the following actions should the healthcare professional take first?
- A. Notify the provider.
- B. Report the incident to the healthcare facility's manager.
- C. Monitor vital signs.
- D. Fill out an incident report.
Correct Answer: C
Rationale: In a situation where the wrong medication has been administered to a client, the immediate priority is to assess and monitor the client's vital signs to identify any adverse effects of the incorrect medication. This action takes precedence over notifying the provider, reporting the incident, or filling out an incident report. Monitoring vital signs allows for timely recognition and intervention if the client experiences any negative reactions to the wrong medication, ensuring their safety and well-being.