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Which of the following meal choices is suitable for a 6-month-old infant?
- A. Egg white, formula, and orange juice
- B. Apple juice, carrots, whole milk
- C. Rice cereal, apple juice, formula
- D. Melba toast, egg yolk, whole milk
Correct Answer: C
Rationale: Rice cereal, apple juice, and formula suit a 6-month-old, aligning with early solid introduction gluten-free, digestible, and safe, per pediatric guidelines. Egg whites risk allergies, whole milk isn't recommended before 1 year, and melba toast is a choking hazard. Nurses advise this menu to support growth, avoiding allergens or hard foods, ensuring nutritional balance for this developmental stage.
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The nurse is completing a health history with an older adult client who reveals smoking one pack of cigarettes daily for the past 50 years. Which illness prevention strategy should the nurse recommend?
- A. Referral to a smoking cessation program
- B. Screening for lung cancer
- C. Referral to a nutritionist
- D. Mobility exercises
Correct Answer: A
Rationale: For an older adult with a 50-year, pack-a-day smoking history, the nurse prioritizes illness prevention via a smoking cessation program referral primary prevention to halt further damage from a modifiable risk tied to lung cancer, COPD, and heart disease. Quitting slashes these risks studies show even late cessation improves lung function. Screening for lung cancer is secondary, detecting issues, not preventing them, though relevant later. Nutrition or mobility exercises enhance wellness but don't address smoking's root threat 20% of smokers develop COPD. Cessation directly targets the habit, aligning with nursing's preventive ethos, offering practical support like group therapy or nicotine aids. This strategy empowers the client to alter a decades-long risk, maximizing health gains despite age, a cornerstone of tailored care.
Which of the following statement best describe implementation in nursing process?
- A. Identifying problems
- B. Setting goals
- C. Carrying out interventions
- D. Evaluating outcomes
Correct Answer: C
Rationale: Implementation is carrying out interventions (C), per nursing process e.g., giving meds. Not identifying (A), setting (B), evaluating (D) action-focused. C best defines implementation's execution, making it correct.
The physician has discussed the need for medication with the parents of an infant with congenital hypothyroidism. The nurse can reinforce the physician's teaching by telling the parents that:
- A. The medication will be needed only during times of rapid growth
- B. The medication will be needed throughout the child's lifetime
- C. The medication schedule can be arranged to allow for drug holidays
- D. The medication is given one time daily every other day
Correct Answer: B
Rationale: Lifetime thyroid hormone replacement is needed for congenital hypothyroidism to prevent developmental delays growth spurts, holidays, or alternate days don't suffice. Nurses reinforce this, ensuring adherence, critical for normal growth in this endocrine disorder.
When charting in the client's record or chart, the nurse most needs to do which one of the following things?
- A. Date and sign each entry.
- B. Chart every two hours.
- C. Use ballpoint pen and not pencil.
- D. Cross out errors so others can't read them.
Correct Answer: A
Rationale: Dating and signing each chart entry is most essential, establishing a legal timeline and accountability for actions. Fixed intervals aren't mandatory, pens ensure permanence but aren't the priority, and crossing out errors risks misinterpretation. This practice validates care, crucial for nursing documentation integrity.
Which of the following nursing intervention is appropriate when an IV infusion infiltrates?
- A. Elevate the site
- B. Discontinue the infusion
- C. Attempt to flush the tube
- D. Apply warm, moist compress
Correct Answer: B
Rationale: IV infiltration (fluid in tissues) requires discontinuing the infusion to stop further leakage, preventing swelling or tissue damage. Elevation reduces edema post-removal, flushing worsens infiltration, and warm compresses aid absorption later. Nurses prioritize stopping the source, then assess for complications like phlebitis, ensuring patient comfort and vein integrity.