Nursing Elites

1. When teaching a parent of a toddler with a new prescription for liquid ferrous sulfate, which of the following instructions should the nurse include?

• A. Mix the medication with milk.
• B. Give the medication with orange juice.
• C. Give the medication with meals.
• D. Administer the medication with an antacid.

Correct answer: B

Rationale: The correct answer is to give the medication with orange juice. Orange juice helps increase the absorption of iron from ferrous sulfate. This acidic environment aids in the absorption of iron, making it a suitable choice for administration. Mixing the medication with milk or an antacid may decrease iron absorption, and giving it with meals may not optimize its absorption as effectively as with orange juice.

2. During a home care visit for an infant diagnosed with gastroesophageal reflux, which parental action observed requires intervention by the nurse?

• A. The infant's formula is mixed with rice cereal.
• B. The mother positions the infant in a high Fowler position while feeding.
• C. After feeding, the infant is placed in a car seat.
• D. The mother administers ranitidine (Zantac) to the infant using a syringe.

Correct answer: C

Rationale: Placing an infant diagnosed with gastroesophageal reflux in a car seat after feeding can increase the risk of reflux and aspiration. The semi-upright or high Fowler position is recommended to help reduce reflux symptoms during feeding. Adding rice cereal to formula can help thicken it and reduce reflux episodes. Administering ranitidine using a syringe is a common method of oral medication administration. Therefore, the action of placing the infant in a car seat after feeding is the one that requires intervention due to the increased risk it poses.

3. Which is the priority nursing assessment when providing care for an infant at risk for dehydration?

• A. Urine output
• B. Urine specific gravity
• C. Vital signs
• D. Daily weight

Correct answer: D

Rationale: The correct answer is Daily weight. Daily weight is a crucial assessment in infants at risk for dehydration because changes in weight can indicate fluid balance and dehydration status. It is essential to monitor daily weight to promptly identify and manage dehydration in infants.

4. A school-age child has peripheral edema. Which of the following assessments should the nurse perform to confirm peripheral edema?

• A. Palpate the dorsum of the child's feet
• B. Weigh the child daily using the same scale
• C. Assess the child's skin turgor
• D. Observe the child for periorbital swelling

Correct answer: A

Rationale: To confirm peripheral edema in a child, the nurse should palpate the dorsum of the child's feet by pressing a fingertip against a bony prominence for 5 seconds. This assessment helps detect the presence of pitting edema, which is characterized by an indentation that remains after the pressure is released.

5. When planning care for a newborn with esophageal atresia and tracheoesophageal fistula, which is the priority nursing diagnosis?

• A. Ineffective Tissue Perfusion
• B. Ineffective Infant Feeding Pattern
• C. Acute Pain
• D. Risk for Aspiration

Correct answer: D

Rationale: The priority nursing diagnosis for a newborn with esophageal atresia and tracheoesophageal fistula is 'Risk for Aspiration' because of the potential respiratory complications associated with these conditions. The newborn is at a higher risk of aspirating oral or gastric contents due to the abnormal connections between the esophagus and trachea, posing a serious threat to the airway and lungs. Addressing this risk is crucial to prevent respiratory distress and maintain the airway's patency, making it the priority nursing diagnosis in this scenario. 'Ineffective Tissue Perfusion' is not the priority as respiratory compromise takes precedence over perfusion concerns. 'Ineffective Infant Feeding Pattern' may be relevant but addressing the risk of aspiration is more critical. 'Acute Pain' is not the priority compared to the life-threatening risk of aspiration.

Similar Questions