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During a physical assessment on a toddler, what should be the first action?
- A. Perform traumatic procedures
- B. Use minimal physical contact
- C. Proceed from head to toe
- D. Explain the exam in detail
Correct Answer: B
Rationale: The correct first action when performing a physical assessment on a toddler is to use minimal physical contact. This approach helps the toddler become comfortable and reduces anxiety during the assessment. Traumatic procedures (Choice A) should never be the first action as they can cause distress. Proceeding from head to toe (Choice C) is a common sequence in physical assessments but does not address the initial need to establish trust and comfort. Explaining the exam in detail (Choice D) is important but should come after establishing a rapport through minimal physical contact.
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A healthcare professional is caring for a client who has a prescription for morphine 5mg IM but accidentally administers the entire 10mg from the single-dose vial. Which of the following actions should the healthcare professional take first?
- A. Complete an incident report
- B. Measure the client's respiratory rate
- C. Report the incident to the pharmacy
- D. Notify the client's provider
Correct Answer: B
Rationale: Assessing the client's respiratory rate is the priority in this situation as overdosing on morphine can lead to respiratory depression, making it crucial to monitor the client's breathing. Completing an incident report (choice A) is important but should not be the first action. Reporting the incident to the pharmacy (choice C) and notifying the client's provider (choice D) are necessary steps but assessing the client's respiratory status takes precedence to ensure immediate safety and intervention.
A client who requires maximal support is being taught how to use a two-wheeled walker by a nurse. Which of the following actions by the client indicates an understanding of the teaching?
- A. The client moves the walker ahead 25.4 cm with each step
- B. The client picks up the walker with each step
- C. The client stands with elbows slightly bent while holding the walker
- D. The client stoops slightly forward when moving the walker
Correct Answer: C
Rationale: The correct answer is C. When using a two-wheeled walker, the client should stand with elbows slightly bent to maintain balance and stability. This position helps distribute weight effectively and promotes proper use of the walker. Choices A, B, and D are incorrect. Choice A does not demonstrate proper posture while using the walker. Choice B of picking up the walker with each step is not the correct technique and can lead to instability. Choice D of stooping slightly forward is also incorrect as it can affect balance and posture negatively.
A parent is reviewing safety measures for an 8-month-old infant with a nurse. Which of the following statements by the parent indicates an understanding of safety for the infant?
- A. "My baby loved to play with the crib gym, but I took it out of the crib."
- B. "I just bought a firm mattress so my baby will sleep better."
- C. "My baby really likes sleeping on the fluffy pillow we just got."
- D. "I put the baby's car seat on the table after I put him in it."
Correct Answer: A
Rationale: Choice A is correct because removing the crib gym prevents potential safety hazards such as choking or entrapment. Choices B, C, and D are incorrect as they pose risks to the infant's safety. A firm mattress is recommended for infants to reduce the risk of suffocation. Soft mattresses and fluffy pillows increase the risk of suffocation and Sudden Infant Death Syndrome (SIDS). Placing the baby's car seat on a table can lead to falls or other accidents.
The patient is being taught about flossing and oral hygiene. What instruction will the nurse include in the teaching session?
- A. Using waxed floss helps prevent bleeding
- B. Flossing removes plaque and tartar from the teeth
- C. Flossing at least 3 times a day is beneficial
- D. Applying toothpaste before flossing is harmful
Correct Answer: B
Rationale: The correct answer is B. Flossing is essential for removing plaque and tartar between teeth, contributing to better oral hygiene. Choice A is not entirely accurate as waxed floss may not solely prevent bleeding. Flossing three times a day, as mentioned in choice C, can be excessive and unnecessary, while choice D is incorrect as applying toothpaste before flossing is not harmful but might not provide additional benefits.
During auscultation of a client experiencing chest pain worsened by inspiration, a nurse hears a high-pitched scratching sound in both systole and diastole with the diaphragm of the stethoscope placed at the left sternal border. Which of the following heart sounds should the nurse document?
- A. Pericardial friction rub
- B. Murmur
- C. S1 and S2
- D. Bruit
Correct Answer: A
Rationale: The correct answer is 'Pericardial friction rub.' A pericardial friction rub is a high-pitched, scratching sound heard in both systole and diastole, which is characteristic of pericardial inflammation. This sound is different from a murmur, which is a swooshing or blowing sound due to turbulent blood flow. S1 and S2 are normal heart sounds, and a bruit is a whooshing sound caused by turbulent blood flow in an artery, not related to pericardial inflammation.