the nurse has completed client teaching about introducing solid foods to an infant to evaluate teaching the nurse asks the mother to identify an appro

NCLEX-PN

Nclex Questions Management of Care

1. The nurse has completed client teaching about introducing solid foods to an infant. To evaluate teaching, the nurse asks the mother to identify an appropriate first solid food. Which of the following is an appropriate response?

A. pureed canned squash
B. pureed apples
C. yogurt
D. infant rice cereal

Correct answer: D

Rationale: The correct answer is infant rice cereal. Single-grain infant cereals are recommended as the first solid food because they are easily digestible and have added iron content. Choice C, yogurt, is incorrect because yogurt is a milk product and should be delayed until the child is 12 months old due to the risk of milk allergy. Choices A and B are incorrect because fruits and vegetables are typically introduced after cereals to help the infant get accustomed to solid foods gradually.

2. When a physician removes a chest tube, which type of dressing is recommended to be placed over the site?

A. transparent dressing
B. colloidal dressing
C. petrolatum gauze
D. nonadherent dressing

Correct answer: C

Rationale: Petrolatum gauze is recommended to be placed over the site when a physician removes a chest tube because it forms an airtight seal, helping prevent air from entering the pleural space. This airtight seal is crucial to avoid complications such as a pneumothorax. Transparent dressing is not ideal for this purpose as it may not provide a sufficient seal due to its design. Colloidal dressing and nonadherent dressing are also not suitable for chest tube removal sites as they do not offer the same level of protection against air leakage and may not provide the necessary sealing properties.

3. For which of the following conditions might blood be drawn to assess uric acid levels?

A. asthma
B. gout
C. diverticulitis
D. meningitis

Correct answer: B

Rationale: Uric acid levels are commonly assessed in patients with gout. Gout is a type of arthritis caused by the buildup of uric acid crystals in the joints, leading to inflammation and pain. Monitoring uric acid levels helps in diagnosing and managing gout. Asthma, diverticulitis, and meningitis are not conditions where blood tests for uric acid levels are typically necessary. Asthma is a respiratory condition, diverticulitis involves inflammation of the digestive tract, and meningitis is an infection of the meninges in the brain and spinal cord.

4. Which of these statements is true regarding advance directives?

A. They must be reviewed and re-signed every 10 years in order to remain valid.
B. An advance directive is legally valid in every state, regardless of the state it was created in.
C. A physician must determine when a client is unable to make medical decisions for themselves.
D. They cannot be honored by EMTs (emergency medical technicians) unless signed by a doctor.

Correct answer: D

Rationale: The correct statement is that advance directives cannot be honored by EMTs unless they are signed by a doctor. EMTs are required to provide emergency care to a client, irrespective of their advance directive status, unless the directive has been signed by a doctor. When a client is brought to the hospital, physicians will assess the client and implement the advance directive if necessary. Advance directives do not need to be reviewed and re-signed every 10 years to remain valid; they remain in effect until changed. While advance directives are legally valid in most states, some states may not honor those created in other states, so it's advisable to check the new state's policies if a client moves. Additionally, it typically requires two physicians, not just one, to determine if a client is unable to make medical decisions for themselves.

5. What is the purpose of the hydraulic lift (Hoyer lift)?

A. To assist clients who have had orthopedic surgery.
B. To assist clients who are unable to stand and extremely obese clients.
C. To assist clients of all ages in a hospital setting.
D. To assist clients with special needs.

Correct answer: B

Rationale: The purpose of the hydraulic lift, also known as the Hoyer lift, is to facilitate safe transfers for clients who cannot stand or are extremely obese. It is specifically designed for assisting clients who are unable to stand and for those who are too heavy for healthcare workers to lift safely. Choice A is incorrect because the primary purpose of a hydraulic lift is not related to orthopedic surgery. Choice C is incorrect because it is too broad and does not capture the specific use of the hydraulic lift. Choice D is incorrect because the lift is not solely for clients with special needs but rather for those who cannot stand or are extremely obese.