Nokea
Which behavior by a female client feeding her newborn demonstrates that she needs more teaching related to safety and infant feeding?
- A. She uses the bulb syringe to help clear her baby's nose when milk is regurgitated.
- B. She places her infant on her right side after feeding her.
- C. She props the bottle in the crib to feed her baby, which allows her to write birth announcements and feed her baby at the same time.
- D. She burps her baby by placing her in a sitting position, supporting her head and neck and gently massaging her back.
Correct Answer: C
Rationale: This practice is the proper use of the bulb syringe to clear the infant's airway in case of regurgitation. Placing the infant on either side or on the stomach prevents aspiration of regurgitated milk. 'Bottle propping' is an unsafe practice because it increases the likelihood of aspiration. This practice is one correct way of burping an infant.
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The client with a recent liver transplant asks the nurse how long he will have to take an immunosuppressant. Which response is correct?
- A. One year
- B. Five years
- C. 10 years
- D. Life
Correct Answer: D
Rationale: Liver transplant recipients require lifelong immunosuppression to prevent graft rejection, as the immune system continuously recognizes the transplant as foreign.
A client with a history of phenylketonuria is seen at the local family planning clinic. After completing the client's intake history, the nurse provides literature for a healthy pregnancy. Which statement indicates that the client needs further teaching?
- A. I can help control my weight by switching from sugar to Nutrasweet.
- B. I need to resume my old diet before becoming pregnant.
- C. I need to eliminate most sources of phenylalanine from my diet.
- D. Fresh fruits and raw vegetables will make excellent between-meal snacks.
Correct Answer: A
Rationale: Nutrasweet (aspartame) contains phenylalanine, which is harmful in phenylketonuria, so this statement indicates a need for further teaching.
The nurse caring for a client with a closed head injury obtains an intracranial pressure (ICP) reading of 17 mmHg. The nurse recognizes that:
- A. The ICP is elevated and the doctor should be notified.
- B. The ICP is normal; therefore, no further action is needed.
- C. The ICP is low and the client needs additional IV fluids.
- D. The ICP reading is not as reliable as the Glasgow coma scale.
Correct Answer: A
Rationale: Normal ICP is 5-15 mmHg. A reading of 17 mmHg is elevated, indicating potential brain swelling, and requires immediate notification of the physician. The Glasgow scale complements but does not replace ICP monitoring.
The primary focus of nursing interventions for the child experiencing sickle cell crisis is aimed toward:
- A. Maintaining an adequate level of hydration
- B. Providing pain relief
- C. Preventing infection
- D. O2 therapy
Correct Answer: A
Rationale: Maintaining the hydration level is the focus for nursing intervention because dehydration enhances the sickling process. Both oral and parenteral fluids are used. The pain is a result of the sickling process. Analgesics or narcotics will be used for symptom relief, but the underlying cause of the pain will be resolved with hydration. Serious bacterial infections may result owing to splenic dysfunction. This is true at all times, not just during the acute period of a crisis. O2 therapy is used for symptomatic relief of the hypoxia resulting from the sickling process. Hydration is the primary intervention to alleviate the dehydration that enhances the sickling process.
What is the appropriate nursing action for a child with increased intracranial pressure?
- A. Head of bed elevated 45 degrees with child's head maintained in a neutral position
- B. Child lying flat
- C. Head turned to side
- D. Frequent visitation for stimulation
Correct Answer: A
Rationale: Elevating the head of the bed to 45 degrees with a neutral head position promotes venous drainage, reducing intracranial pressure.