Nokea
Which of the following infants is in need of additional growth assessment?
- A. Baby girl A: age 4 months, BW 7 lbs. 6 oz., present weight 14 lbs. 14 oz.
- B. Baby girl B: age 2 weeks, BW 6 lbs. 10 oz., present weight 6 lbs. 11 oz.
- C. Baby girl C: age 6 months, BW 8 lbs. 9 oz., present weight 15 lbs. 0 oz.
- D. Baby girl D: age 2 months, BW 7 lbs. 2 oz., present weight 9 lbs. 10 oz.
Correct Answer: B
Rationale: Baby B has gained only 1 oz. in 2 weeks, indicating poor growth (normal is 0.5-1 oz./day). Others show appropriate weight gain.
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The nurse is teaching a client with chronic kidney disease about dietary restrictions. Which of the following foods should the nurse advise the client to limit?
- A. Fresh strawberries.
- B. Baked chicken.
- C. Potato chips.
- D. Brown rice.
Correct Answer: C
Rationale: Potato chips are high in sodium and potassium, which must be limited in chronic kidney disease to prevent fluid retention and hyperkalemia. Options A, B, and D are more suitable: strawberries are low-potassium, chicken is protein-rich, and brown rice is acceptable in moderation.
The nurse is preparing to discharge a client after an abdominal cholecystectomy for treatment of cholelithiasis. The client will go home with a T-tube in place. Which of the following statements, if made by the client to the nurse, indicates a need for further teaching?
- A. It will be great to finally get home, take a shower, and wash my hair.
- B. If the amount of drainage increases over the next several days, I should call my physician.
- C. I can resume swimming laps three times a week at my health club.
- D. I will check the skin around the tube once a day to see how it is doing.
Correct Answer: C
Rationale: Swimming submerges the T-tube, risking infection, indicating a need for further teaching. Options A, B, and D are correct: showering is allowed, increased drainage requires reporting, and daily skin checks prevent complications.
The nurse is teaching a client with a new diagnosis of epilepsy about phenytoin (Dilantin). Which of the following statements by the client indicates a need for further teaching?
- A. I should brush my teeth regularly.
- B. I should report any skin rashes to my doctor.
- C. I should avoid drinking grapefruit juice.
- D. I should stop this medication if my seizures stop.
Correct Answer: D
Rationale: Stopping phenytoin when seizures stop is incorrect, as epilepsy often requires lifelong treatment to prevent recurrence. Options A, B, and C are correct: oral hygiene prevents gingival hyperplasia, rashes may indicate hypersensitivity, and grapefruit juice does not significantly affect phenytoin.
A woman has returned from surgery after a right mastectomy with an IV of 0.9% NaCl infusing at 100 cc/hour into her left forearm. Several hours later, the IV infiltrates. The nurse is supervising a student nurse preparing to insert a new peripheral intravenous catheter. The nurse would intervene in which of the following situations?
- A. The student nurse selects a site where the veins are soft and elastic.
- B. The student nurse selects a site on the distal portion of the left arm.
- C. The student nurse selects a site close to the joint to provide for stability.
- D. The student nurse holds the skin taut to stabilize the vein.
Correct Answer: C
Rationale: inappropriate; movement in area could cause displacement
A client hospitalized with a fractured mandible is to be discharged. Which piece of equipment should be kept on the client with a fractured mandible?
- A. Wire cutters
- B. Oral airway
- C. Pliers
- D. Tracheostomy set
Correct Answer: A
Rationale: Wire cutters are essential for a fractured mandible with wiring, in case of emergency airway obstruction. Oral airway , pliers , and tracheostomy set are not standard.