Nokea
Which of these findings would the nurse most closely associate with anemia in a 10-month-old infant?
- A. Hemoglobin level of 12 g/dL
- B. Pale mucosa of the eyelids and lips
- C. Hypoactivity
- D. A heart rate between 140 to 160
Correct Answer: B
Rationale: The correct answer is B. Pale mucosa of the eyelids and lips is a classic sign of anemia in infants, indicating a lack of sufficient red blood cells. This finding is due to decreased hemoglobin levels, which causes reduced oxygen delivery to tissues. Choices A, C, and D are less specific to anemia in infants. While a hemoglobin level of 12 g/dL may be within the normal range for a 10-month-old infant, the presence of pale mucosa is a more indicative sign of anemia.
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After a client was taken off the ventilator following surgery, they have a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client?
- A. Allow the client to suck on ice chips
- B. Provide mints to freshen the breath
- C. Perform frequent oral care with a tooth sponge
- D. Swab the mouth with glycerin swabs
Correct Answer: C
Rationale: Performing frequent oral care with a tooth sponge is the most appropriate nursing measure to provide comfort to a client with a nasogastric tube draining bile-colored liquids. This measure helps to maintain oral hygiene, prevent dryness, and enhance overall comfort. Allowing the client to suck on ice chips may not address oral hygiene needs, providing mints focuses more on breath freshness rather than comfort, and swabbing the mouth with glycerin swabs may not effectively address oral care needs.
A client is being treated for congestive heart failure with furosemide (Lasix). Which of these findings would be most concerning to the nurse?
- A. Increased urine output
- B. Decreased appetite
- C. Weight loss of 2 kg in 24 hours
- D. Blood pressure of 140/90 mm Hg
Correct Answer: C
Rationale: The correct answer is C. A rapid weight loss of 2 kg in 24 hours suggests significant fluid loss, which is concerning in clients on diuretics like furosemide. Increased urine output (choice A) is an expected effect of diuretic therapy. Decreased appetite (choice B) is a common side effect but not as concerning as rapid weight loss. Blood pressure of 140/90 mm Hg (choice D) is slightly elevated but not the most concerning finding in a client being treated for congestive heart failure with furosemide.
A client with a history of pancreatitis should avoid which of the following food choices?
- A. Noodles
- B. Vegetable soup
- C. Baked fish
- D. Cheddar cheese
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client is diagnosed with methicillin-resistant Staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client?
- A. Reverse
- B. Airborne
- C. Standard precautions
- D. Contact
Correct Answer: D
Rationale: The correct answer is 'D: Contact.' Contact precautions are necessary for clients with MRSA pneumonia to prevent the spread of the resistant bacteria. MRSA is primarily spread by direct contact, so using contact precautions, such as wearing gloves and gowns, is essential. Choice A, 'Reverse,' is not a type of isolation precaution. Choice B, 'Airborne,' is not the appropriate isolation for MRSA pneumonia, as MRSA is not transmitted through the airborne route. Choice C, 'Standard precautions,' are important for all clients, but for MRSA pneumonia specifically, contact precautions are more targeted and necessary.
A middle-aged woman talks to the nurse in the healthcare provider's office about uterine fibroids, also called leiomyomas or myomas. What statement by the woman indicates more education is needed?
- A. I am one of every 4 women that get fibroids, and among women my age - between the 30s or 40s, fibroids occur more frequently.
- B. My fibroids are noncancerous tumors that grow slowly.
- C. The associated problems I have had are pelvic pressure and pain, urinary incontinence, frequent urination, urine retention, and constipation.
- D. Fibroids that cause no problems still need to be taken out.
Correct Answer: D
Rationale: The correct answer is D because fibroids that are asymptomatic usually do not require treatment or removal. The statement 'Fibroids that cause no problems still need to be taken out' indicates a need for further education. Choice A correctly states the frequency of fibroids in women and their age group. Choice B accurately describes fibroids as noncancerous slow-growing tumors. Choice C lists common symptoms associated with uterine fibroids.