Nokea
Which statement by a parent would alert the nurse to assess for iron deficiency anemia in a 14 month-old child?
- A. I know there is a problem since my baby is always constipated.
- B. My child doesn't like many fruits and vegetables, but she really loves her milk.
- C. My child is not eating as much as she did 4 months ago.
- D. My child doesn't drink a whole glass of juice or water at 1 time.
Correct Answer: B
Rationale: My child doesn't like many fruits and vegetables, but she really loves her milk. Excessive milk intake can displace iron-rich foods, leading to iron deficiency anemia.
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The nurse is discussing positioning with the family of a client who is at home following a total hip replacement a week ago. Which should be included in the discussion?
- A. Keep the client on his unaffected side most of the time.
- B. Position the client to maintain hip flexion.
- C. Keep a pillow between his legs when turning him.
- D. Position the client so the hip is adducted.
Correct Answer: C
Rationale: A pillow between the legs maintains hip abduction, preventing dislocation post-hip replacement, a critical positioning instruction.
The nurse is caring for a client who has a prescription for ampicillin 1.5 g IV in 100 mL of 0.9% sodium chloride to be administered over 30 minutes. The nurse has tubing with a drop factor of 15 available. How many gtts/min should the client receive? Record your answer using a whole number.
Correct Answer: 50
Rationale: Flow rate = (100 mL / 30 min) x (15 gtts/mL) = 50 gtts/min (A).
The nurse caring for a 2-year-old client should expect the child to be able to perform which of the following actions? Select all that apply.
- A. Draw a square
- B. Hop on one foot
- C. Kick a large ball
- D. Use 2-word phrases
- E. Walk without help
Correct Answer: C, D, E
Rationale: A 2-year-old can kick a ball (C), use 2-word phrases (D), and walk without help (E). Drawing a square (A) and hopping on one foot (B) are skills typically developed later.
The nurse is providing care to a client with posttraumatic stress disorder following a terrorist attack at the client's place of worship. The client says, 'I'm just so worried all the time. I will never be safe again!' What is the priority nursing action?
- A. Acknowledge the client's feelings
- B. Assess the client's support system
- C. Encourage the client to talk about the trauma
- D. Offer the client a PRN sleep medication
Correct Answer: A
Rationale: Acknowledging feelings (A) builds trust and validates the client's experience, making it the priority. Assessing support (B), discussing trauma (C), or offering medication (D) are secondary.
The nurse is inserting an indwelling urinary catheter for a male client. After inserting the catheter 6 inches (15.2 cm), the nurse notes a small amount of urine in the tubing. Which of the following actions should the nurse take next?
- A. Measure the urine output.
- B. Immediately inflate the balloon.
- C. Secure the catheter tubing to the client's leg.
- D. Continue to advance the catheter to the bifurcation.
Correct Answer: D
Rationale: Advancing to the bifurcation (D) ensures proper placement in the bladder before inflating the balloon. Measuring output (A), inflating early (B), or securing (C) are premature.