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 B

Explanation

Rationale:

A. "This helps to keep you hydrated.": Flushing an intermittent infusion device does not hydrate the client, as the small amount of saline used is not intended for fluid replacement. Hydration is achieved through continuous or scheduled fluid administration, not flushes.

B. "This clears blood from the tubing and the catheter.": Flushing helps maintain catheter patency by preventing blood from clotting inside the lumen. It ensures the device remains functional and ready for medication administration when needed.

C. "This makes sure it stays sterile.": Flushing does not sterilize the device. Sterility is maintained through proper handling and use of aseptic technique. The purpose of flushing is mechanical, not antimicrobial.

D. "This prevents leakage of fluid and medication.": While flushing may help confirm that the device is intact, the primary reason is not to prevent leakage but to maintain patency and ensure the catheter is free of occlusions.

A. A client must create a do-not-resuscitate order when completing advance directives. B. Advance directives cannot be changed once implemented. C. Assigning a health care surrogate requires legal consultation. D. A health care surrogate makes health care decisions when the client is no longer able.

Correct Answer is D

Explanation

Rationale:

A. A client must create a do-not-resuscitate order when completing advance directives: A DNR is a separate medical order and is not required when completing advance directives. Clients may choose to include resuscitation preferences in their directive but are not obligated to.

B. Advance directives cannot be changed once implemented: Advance directives are flexible documents that can be revised or revoked by the client at any time, as long as the client is mentally competent. This allows clients to adjust their wishes as circumstances or preferences change.

C. Assigning a health care surrogate requires legal consultation: While laws vary by state, in most cases, a legal consultation is not required. Clients can designate a surrogate by completing a form that is often available at healthcare facilities or through state-provided templates.

D. A health care surrogate makes health care decisions when the client is no longer able: A surrogate, also known as a durable power of attorney for health care, steps in only when the client loses decision-making capacity. This ensures that the client’s preferences are respected when they cannot communicate them.

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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 flushing a client's intermittent infusion device. The client states, "Why do you have to do that if you are not giving me medicine?" Which of the following statements should the nurse make?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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