A nurse is assessing a 3-month-old infant whose parents report starting cow's milk feedings 1 week ago. Which of the following actions should the nurse take?

Instruct the parent to give 5 mcg of vitamin D daily.

Instruct the parent to give the infant water every 3 hr between feedings.

Advise the parent to avoid giving cow's milk to the infant prior to 1 year of age.

Recommend the parent mix the milk with rice cereal for feedings.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Instruct the parent to give 5 mcg of vitamin D daily: While vitamin D supplementation is recommended for breastfed infants, this advice does not address the inappropriate introduction of cow’s milk, which can cause complications such as intestinal bleeding and iron deficiency in infants under 12 months.

B. Instruct the parent to give the infant water every 3 hr between feedings: Offering water to infants under 6 months is discouraged, as it can displace essential nutrients from breast milk or formula and increase the risk of water intoxication due to immature kidneys.

C. Advise the parent to avoid giving cow's milk to the infant prior to 1 year of age: Cow's milk is not suitable for infants under 12 months because it lacks adequate iron and nutrients, and its high protein content can irritate the immature kidneys and intestinal lining.

D. Recommend the parent mix the milk with rice cereal for feedings: Mixing cow’s milk with cereal does not resolve its nutritional inadequacy or potential risks. Introducing solids and allergenic foods should follow developmental readiness and established pediatric guidelines.

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Correct Answer is C

Explanation

Rationale:

A. Encourage the client to attend a group therapy session: This action does not immediately address the restraint status. The client’s calm and cooperative behavior should prompt reassessment of restraint necessity before introducing other interventions.

B. Continue to monitor the client every 15 min: Ongoing monitoring is important but it is not the priority once the client has de-escalated. If the behavior no longer warrants restraints, the nurse should act promptly to remove them to preserve the client’s rights and dignity.

C. Remove the restraints from the client: Restraints should be discontinued as soon as the client demonstrates self-control and no longer poses a risk to themselves or others. Keeping restraints on unnecessarily can lead to psychological harm, reduced mobility, and legal/ethical violations.

D. Offer the client PRN pain medication: Offering pain medication assumes the client is experiencing discomfort, but there is no indication of pain in the scenario. Medication is not the priority when behavioral signs point to de-escalation and restraint removal is warranted.

A. "Apply the ointment to the skin every 4 hr." B. "Spread the ointment in a thin, even layer.” C. "Apply the ointment to the forearm." D. "Massage the ointment into the skin."

Correct Answer is B

Explanation

Rationale:

A. "Apply the ointment to the skin every 4 hr.": Nitroglycerin topical ointment is applied every 6 to 8 hours, depending on the provider's instructions. Applying it every 4 hours may increase the risk of side effects such as hypotension or tolerance due to excessive dosing frequency.

B. "Spread the ointment in a thin, even layer.": The medication should be applied in a thin, consistent layer to allow for proper absorption through the skin. The dose is usually measured and spread using applicator paper, avoiding rubbing or massaging it in.

C. "Apply the ointment to the forearm.": The preferred application sites are hairless areas of the chest, back, or upper arms. The forearm is not typically used due to variability in absorption and the presence of thinner skin and more movement.

D. "Massage the ointment into the skin.": Nitroglycerin ointment should never be massaged into the skin. Massaging can lead to unpredictable absorption rates and an increased risk of hypotension or headache due to rapid systemic absorption.

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A nurse is assessing a 3-month-old infant whose parents report starting cow's milk feedings 1 week ago. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who was placed in restraints for aggressive behavior. The client is now calm and cooperative. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is providing teaching to a client who has a new prescription for nitroglycerin topical ointment. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

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