GCC 251 - 275

What information should the nurse give a new mother regarding the introduction of solid foods for her infant?

• Solid foods should not be given until the extrusion reflex disappears, at 8-10 months of age.
• Solid foods should be introduced one at a time, with 4- to 7-day intervals.
• Solid foods can be mixed in a bottle or infant feeder to make feeding easier.
• Solid foods should begin with fruits and vegetables.

Answer explanation

Option 1: Solid foods should not be given until the extrusion reflex disappears, at 8-10 months of age.

Option 2: Solid foods should be introduced one at a time, with 4- to 7-day intervals.

Option 3: Solid foods can be mixed in a bottle or infant feeder to make feeding easier.

Option 4: Solid foods should begin with fruits and vegetables.

Correct Option: Option 2 – Solid foods should be introduced one at a time, with 4- to 7-day intervals.

Explanation: Introduce solids one at a time every 4–7 days. The extrusion reflex fades at 3–4 months.

The LPN is preparing to administer an injection of vitamin K to the newborn. The nurse should administer the injection in the:

• Rectus femoris muscle
• Vastus lateralis muscle
• Deltoid muscle
• Dorsogluteal muscle

Answer explanation

Option 1: Rectus femoris muscle

Option 2: Vastus lateralis muscle

Option 3: Deltoid muscle

Option 4: Dorsogluteal muscle

Correct Option: Option 2 – Vastus lateralis muscle

Explanation: Vastus lateralis is best for newborns; other muscles aren't well developed or safe.

Immediately following the removal of a chest tube, the nurse would:

• Order a chest x-ray
• Take the blood pressure
• Cover the insertion site with a Vaseline gauze
• Ask the client to perform the Valsalva maneuver

Answer explanation

Option 1: Order a chest x-ray

Option 2: Take the blood pressure

Option 3: Cover the insertion site with a Vaseline gauze

Option 4: Ask the client to perform the Valsalva maneuver

Correct Option: Option 3 – Cover the insertion site with a Vaseline gauze

Explanation: Seal site with Vaseline gauze to prevent air entry and potential lung collapse.

When planning to teach an adolescent female patient about PID, which of the following statements should the nurse include?

• Good hygiene practices prevent the development of PID.
• The use of hormonal contraceptives decreases the risk of PID.
• PID can lead to long-term complications of the reproductive tract.
• Infants born to adolescents with PID are at risk for birth defects.

Answer explanation

Option 1: Good hygiene practices prevent the development of PID.

Option 2: The use of hormonal contraceptives decreases the risk of PID.

Option 3: PID can lead to long-term complications of the reproductive tract.

Option 4: Infants born to adolescents with PID are at risk for birth defects.

Correct Option: Option 3 – PID can lead to long-term complications of the reproductive tract.

Explanation: PID may cause reproductive damage such as infertility or ectopic pregnancy.

The nurse is preparing a client for a lumbar puncture. Which is the appropriate position for the client?

• Prone with a pillow under the abdomen.
• Side-lying.
• Side-lying with chin to chest and knees pulled up to chest.
• Side-lying in semi-Fowler's position.

Answer explanation

Option 1: Prone with a pillow under the abdomen.

Option 2: Side-lying.

Option 3: Side-lying with chin to chest and knees pulled up to chest.

Option 4: Side-lying in semi-Fowler's position.

Correct Option: Option 3 – Side-lying with chin to chest and knees pulled up to chest.

Explanation: Flexed side-lying position opens vertebrae for needle access.

A client is admitted with a Ewing's sarcoma. Which symptoms would be expected due to this tumor's location?

• Hemiplegia
• Aphasia
• Nausea
• Bone pain

Answer explanation

Option 1: Hemiplegia

Option 2: Aphasia

Option 3: Nausea

Option 4: Bone pain

Correct Option: Option 4 – Bone pain

Explanation: Ewing’s sarcoma is a bone cancer — bone pain is a key symptom.

Which parameter should the nurse monitor frequently while a patient receives pentamidine isethionate?

• Heart rate
• Electrolyte levels
• Blood sugar levels
• CBC

Answer explanation

Option 1: Heart rate

Option 2: Electrolyte levels

Option 3: Blood sugar levels

Option 4: CBC

Correct Option: Option 3 – Blood sugar levels

Explanation: Drug may induce diabetes — blood sugar monitoring is essential.

Which of the following instructions should be included in the nurse's teaching regarding oral contraceptives?

• Weight gain should be reported to the physician.
• An alternate method of birth control is needed when taking antibiotics.
• If the client misses one or more pills, two pills should be taken per day for 1 week.
• Changes in the menstrual flow should be reported to the physician.

Answer explanation

Option 1: Weight gain should be reported to the physician.

Option 2: An alternate method of birth control is needed when taking antibiotics.

Option 3: If the client misses one or more pills, two pills should be taken per day for 1 week.

Option 4: Changes in the menstrual flow should be reported to the physician.

Correct Option: Option 2 – An alternate method of birth control is needed when taking antibiotics.

Explanation: Antibiotics can reduce effectiveness; use backup contraception during use.

The nurse is monitoring a client admitted with an overdose of Phenobarbital (phenobarbital). The nurse should carefully observe the client for signs of:

• Hyperthermia
• Decreased respirations
• Increased blood pressure
• Dysuria

Answer explanation

Option 1: Hyperthermia

Option 2: Decreased respirations

Option 3: Increased blood pressure

Option 4: Dysuria

Correct Option: Option 2 – Decreased respirations

Explanation: CNS depressant — can cause apnea or dangerously low respiratory rate.

The nurse cares for a client who has a continuous passive motion (CPM) machine in place after a total knee replacement. The physician writes orders for the degree of flexion and hours per day of CPM use. Which intervention should the nurse perform?

• Turn off the CPM machine when the client is eating.
• Check the flexion settings every morning.
• Educate the family on how to change the degree of flexion.
• Increase the degree of flexion per the client's tolerance.

Answer explanation

Option 1: Turn off the CPM machine when the client is eating.

Option 2: Check the flexion settings every morning.

Option 3: Educate the family on how to change the degree of flexion.

Option 4: Increase the degree of flexion per the client's tolerance.

Correct Option: Option 1 – Turn off the CPM machine when the client is eating.

Explanation: Shut off CPM during meals for comfort; only providers should adjust settings.