EXAM 2 REMED

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California Baptist University *

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NUR 215

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Health Science

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May 2, 2024

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pdf

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23

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10/27/23, 7 : 27 AM Elsevier Adaptive Quizzing - Quiz performance Page 1 of 23 https://eaqng.elsevier.com/#/quizPerformance/45766862 Exit Performance Exam 2 Remediation NCLEX-PN EAQ: Fluid, Electrolytes and Nutrition Due Nov 10, 2023 by 11:59 pm Final Score 100% 30 out of 30 questions answered correctly Completed on Oct 26, 2023 10:53 am Incorrect (0) Correct (30)
10/27/23, 7 : 27 AM Elsevier Adaptive Quizzing - Quiz performance Page 2 of 23 https://eaqng.elsevier.com/#/quizPerformance/45766862 On the second day of life, minutes after drinking 2 oz of formula, a newborn regurgitates about half an ounce. The mother remarks, "My baby spits up after every feeding." Which would the nurse do next? A tapwater enema is prescribed for a 6-month-old infant with suspected Hirschsprung disease. Which rationale causes the nurse to question this prescription? Rationale Holding the infant upright enables gravity to move the food through the pyloric sphincter, minimizing regurgitation. Although it is common for infants to regurgitate, telling the mother this will not enhance feedings. The infant has had enough formula and does not require more during this feeding, so feeding more in the nursery is not necessary. A newborn should not be propped up after feeding because pressure of the abdomen on the stomach puts pressure on the esophagus, which could precipitate regurgitation. Test-Taking Tip: Avoid selecting answers that state hospital rules or regulations as a reason or rationale for action. Reassure the mother that many babies spit up some milk at first. Suggest that she hold her baby upright for 30 minutes after feeding. Feed a small amount of fresh formula when the baby returns to the nursery. Teach the mother how to prop the baby in an infant seat for 1 hour after feeding. Enemas are contraindicated in infants.
10/27/23, 7 : 27 AM Elsevier Adaptive Quizzing - Quiz performance Page 3 of 23 https://eaqng.elsevier.com/#/quizPerformance/45766862 Which population would benefit from an annual influenza vaccination program for members of a community? Select all that apply. One, some, or all responses may be correct. Rationale Tapwater enemas are hypotonic and are contraindicated; they may cause increased absorption of fluid through the bowel and may upset the balance of fluid in the body. Such enemas also interfere with the potassium ion balance; this electrolyte can be lost by way of the large intestine. The enema removes waste products from the bowel, not nutrients. Fear of intrusive procedures is typical of preschoolers, not infants. The temperature of the water is regulated, so this is not a concern. Rationale People who would benefit from annual influenza vaccination would include It could cause a fluid and electrolyte imbalance. It could increase the fear of intrusive procedures. The result could cause shock from a sudden drop in temperature. Pregnant women Health care workers People older than age 50 Chronic medical conditions Children between 6 and 59 months
10/27/23, 7 : 27 AM Elsevier Adaptive Quizzing - Quiz performance Page 4 of 23 https://eaqng.elsevier.com/#/quizPerformance/45766862 A client is instructed to eat a nutrient-rich diet as a means of supporting the body's natural defense mechanisms. Which nutrients would the nurse encourage the client to include in her diet? pregnant women, health care workers, people older than 50 years, those with chronic medical conditions, and children between the ages of 6 to 59 months. These populations are at highest risk for developing influenza. Test-Taking Tip: Because few things in life are absolute without exceptions, avoid selecting answers that include words such as always, never, all, every, and none. Answers containing these key words are rarely correct. Rationale Vitamins A, C, and E and selenium are immune-stimulating nutrients. Too much emphasis on fat-soluble vitamins may result in an inadequate intake of important water-soluble vitamins and minerals. Dietary fiber, oat bran, and low-fat foods with essential fatty acids have no known e ff ect on natural defenses. Fat-soluble vitamins Dietary fiber and oat bran Low-fat foods with essential fatty acids Vitamins A, C, and E and selenium
10/27/23, 7 : 27 AM Elsevier Adaptive Quizzing - Quiz performance Page 5 of 23 https://eaqng.elsevier.com/#/quizPerformance/45766862 A severely dehydrated infant admitted to the pediatric unit is too lethargic to receive oral rehydration therapy, and an intravenous infusion is started. Which activity is the nurse's primary responsibility? When taking the blood pressure of a client who had a thyroidectomy, the nurse identifies that the client is pale and has spasms of the hand. The nurse notifies the health care provider. Which substance would the nurse expect the health care provider to prescribe? Rationale It is critical to infuse the prescribed fluid over the prescribed time to gradually restore fluid and electrolyte balance. Cuddling should be o ff ered, preferably by the significant caregiver, because after the infant's physical needs have been met the emotional needs become the priority. Documentation should be performed after the infusion has been instituted and the infant's response is evaluated. Although explaining the purpose of the infusion is important, it is secondary to the physiologic safety of the infant. Test-Taking Tip: Answer every question because on the NCLEX exam you must answer a question before you can move on to the next question. Monitoring the prescribed rate of flow Cuddling the infant during the infusion Documenting the changes in the infant's behavior Explaining the purpose of the infusion to the parent Calcium
10/27/23, 7 : 27 AM Elsevier Adaptive Quizzing - Quiz performance Page 6 of 23 https://eaqng.elsevier.com/#/quizPerformance/45766862 The clinic nurse is teaching an adolescent about lifestyle modifications to prevent hyperlipidemia. Which statement by the adolescent indicates a need for further teaching? Rationale These signs may indicate calcium depletion as a result of removal of parathyroid glands during thyroidectomy. Symptoms associated with hypomagnesemia include tremor, neuromuscular irritability, and confusion. Symptoms associated with metabolic acidosis include deep, rapid breathing, weakness, and disorientation. Symptoms associated with hypokalemia include muscle weakness and dysrhythmias. Test-Taking Tip: Avoid selecting answers that state hospital rules or regulations as a reason or rationale for action. Rationale Magnesium Bicarbonate Potassium chloride "I'll start eating more red meat." "I'm going to eat a lot of low-fat yogurt." "I'll try to stop eating so much processed food." "I'll start eating whole-grain bread instead of white bread."
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