A 9-month old is seen in the well child clinic. During the n...

A 9-month old is seen in the well child clinic. During the nursing assessment, the mother asks, 'Shouldn't he be making baby sounds by now? My friend's little boy is the same age and he is already saying dada.' The nurse reports the mother's concerns to the doctor for follow-up based on the knowledge that infants should be making rudimentary sounds by age:

A. 1 month
B. 2 months
C. 4 months
D. 8 months

Correct Answer: D

Rationale: Infants typically make cooing or babbling sounds by 6-8 months. Lack of sounds at 9 months warrants evaluation.

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A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make?

A. Why don't we now have the client turn back to the left side.
B. That was done correctly. Did you have any problems with the insertion?
C. Let's check to see if the suppository is in far enough.
D. Did you feel any stool in the intestinal tract?

Correct Answer: B

Rationale: Left side-lying position is the optimal position for the client receiving rectal medications. Due to the position of the descending colon, left side-lying allows the medication to be inserted and move along the natural curve of the intestine and facilitates retention of the medication.

The nurse in an outpatient clinic is caring for a client at 34 weeks gestation. The client is taking ferrous sulfate for anemia and reports constipation. Which of the following recommendations should the nurse reinforce for this client? Select all that apply.

A. Decreased daily intake of dairy products
B. Increased intake of fruits and vegetables
C. Moderate-intensity exercise regularly
D. One stimulant laxative daily for a week
E. Two cups of hot coffee each morning

Correct Answer: B,C

Rationale: Fruits and vegetables provide fiber, and exercise promotes bowel motility, relieving constipation. Dairy may worsen constipation, stimulant laxatives are not first-line in pregnancy, and coffee is not a primary solution.

The nurse is performing a sterile dressing change for a client when a second client begins yelling for pain medication. Which of the following actions should the nurse take?

A. Ask unlicensed assistive personnel (UAP) to take the second client’s vital signs and report back immediately
B. Direct UAP to ask the second client to rate the pain on a 0-10 scale and report back immediately
C. Inform UAP to tell the second client that the nurse will be there soon and complete the sterile dressing change
D. Interrupt the dressing change to medicate the second client

Correct Answer: C

Rationale: Completing the sterile dressing change maintains sterility and infection control, while informing the UAP to reassure the second client ensures their needs are addressed promptly without compromising the first client’s care.

The nurse is reinforcing information for a client with chronic obstructive pulmonary disease. Which statements by the client indicate an understanding of the pursed-lip breathing technique? Select all that apply.

A. I exhale for 2 seconds through pursed lips
B. I exhale for 4 seconds through pursed lips
C. I inhale for 2 seconds through my mouth
D. I inhale for 2 seconds through my nose, keeping my mouth closed
E. I inhale for 4 seconds through my nose, keeping my mouth closed

Correct Answer: B,D

Rationale: Pursed-lip breathing involves inhaling 2 seconds through the nose (mouth closed) and exhaling 4 seconds through pursed lips to prolong exhalation and reduce air trapping in COPD.

The nurse is caring for a client who performs frequent urinary self-catheterizations. Which of the following client assessments would indicate a potential for a latex allergy? Select all that apply.

A. History of angioedema with lisinopril
B. History of epilepsy
C. Known allergy to avocados and bananas
D. Known allergy to shellfish
E. Lip swelling when blowing up balloons

Correct Answer: C,E

Rationale: Allergies to avocados, bananas, and latex (balloons) indicate a potential latex allergy due to cross-reactivity. Angioedema with lisinopril, epilepsy, and shellfish allergies are unrelated to latex sensitivity.