Nokea
The nurse is leading a class for expectant mothers.
Which of the following comments would indicate to the nurse that a pregnant woman understands the recommended dietary caloric increase for pregnancy?
- A. I will need to double my calorie intake since I am now eating for two of us.'
- B. I can add an additional 500 calories by drinking milkshakes.'
- C. I need to add 300 calories by increasing my intake of the four basic food groups.'
- D. I really need to watch my calorie intake so I will not gain too much weight.'
Correct Answer: C
Rationale: Strategy: Determine the outcome of each answer choice. Is it desired? (1) common misconception (2) 500 calories is too many calories, and a milkshake is not a good food source because of its fat content (3) correct-recommended to increase calorie intake by 300 for fetal growth, maternal tissues, and the placenta (4) unsafe for the pregnant client
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A five-year-old is scheduled for a lumbar puncture (LP). Which of the following nursing actions would BEST prepare the child for the procedure?
- A. Explain the procedure in detail.
- B. Show a video of the procedure.
- C. Do a mock run-through of the procedure.
- D. Answer all questions simply and honestly.
Correct Answer: C
Rationale: excellent method to use with a child because it incorporates actually 'feeling' many aspects of the procedure as they are explained
The nurse is caring for a client in the ICU. Hemodynamic monitoring is accomplished via a Swan-Ganz catheter. The nurse is aware that this type of monitoring will provide which of the following information?
- A. Measures the circulatory volume in the coronary arteries.
- B. Indirectly measures the pressure in the ventricles.
- C. Analyzes the adequacy of pulmonary circulation.
- D. Directly measures the adequacy of CO2 exchange.
Correct Answer: B
Rationale: CVP readings measure the pressure in the right ventricle, the Swan-Ganz catheter measures the pulmonary artery wedge pressure, which is an indirect reading of the pressure in the left ventricle
An elderly man is admitted to a medical unit with shortness of breath and is diagnosed with an upper respiratory infection (URI). He is placed on droplet precautions. The nurse has just finished giving him his PO medications. As the nurse leaves his room, the nurse should
- A. wash hands, remove the gown and mask, and throw the trash in a container outside of the room.
- B. remove the mask, wash hands, and throw the trash in a container inside the room.
- C. wash hands, remove the mask, and throw the trash in a container inside the room.
- D. remove the gown and gloves, wash hands, remove the mask, and throw the trash in a container inside the room.
Correct Answer: C
Rationale: hands should be washed before removing mask to prevent transfer of microbes to face
Which of the following nursing actions should be the priority for an infant admitted with a positive stool culture for Salmonella?
- A. Change the diet to clear liquids.
- B. Initiate intravenous fluids.
- C. Maintain contact precautions.
- D. Apply cloth diapers.
Correct Answer: C
Rationale: prevents transmission of this bacterium to other individuals
The nurse is caring for a 33-year-old woman after delivering an 8 lb 4 oz girl with talipes equinovarus. The woman confides to the nurse, 'I feel so bad that my baby is abnormal.' Which of the following responses by the nurse is BEST?
- A. It's understandable that you feel this way, but there are treatments to correct your baby's problem.
- B. Your baby is not really abnormal. Her feet just look different because of the way the muscles pull.
- C. You have nothing to feel guilty about. The abnormality is not your fault.
- D. Don't feel bad. You baby's abnormality can be corrected surgically.
Correct Answer: A
Rationale: accepts feelings and gives correct information, serial casting is used