Nokea
The nurse assesses the development of a three-month-old boy in the well-baby clinic.
- A. Which behavior in a three-month-old boy would be unexpected?
- B. The boy holds his head erect when sitting on the examination table.
- C. The boy tries to grasp a toy just out of reach.
- D. The boy turns his head to try to locate a sound.
- E. The boy smiles spontaneously when he sees his mother.
Correct Answer: B
Rationale: Grasping for objects out of reach is unexpected until around 6 months of age. Holding the head erect, turning toward sounds, and spontaneous smiling are developmentally appropriate for a three-month-old.
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Which of the following is the BEST method for the nurse to use when evaluating the effectiveness of tracheal suctioning?
- A. Note subjective data, such as 'My breathing is much improved now.'
- B. Note objective findings, such as decreased respiratory rate and pulse.
- C. Consult with the respiratory therapist to determine effectiveness.
- D. Auscultate the chest for change or clearing of adventitious breath sounds.
Correct Answer: D
Rationale: to assess the effectiveness of suctioning, auscultate the client's chest to determine if the adventitious sounds are cleared and to ensure that the airway is clear of secretions.
The nurse is performing physical assessments on adolescents. What finding would the nurse anticipate concerning female growth spurts?
- A. They occur about 2 years earlier than for males.
- B. They begin about the same time for males.
- C. They begin just prior to the onset of puberty.
- D. They are characterized by an increase in height of 4 inches each year.
Correct Answer: A
Rationale: They occur about 2 years earlier than for males. Females experience a growth spurt about 2 years earlier than their male peers.
The nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following laboratory results should the nurse monitor closely?
- A. Serum potassium and glucose.
- B. Serum cholesterol and triglycerides.
- C. Serum calcium and magnesium.
- D. Serum sodium and chloride.
Correct Answer: A
Rationale: TPN can cause hyperglycemia and hypokalemia; monitoring potassium and glucose is critical. Options B, C, and D are less immediately relevant.
The nurse is teaching a client with a new diagnosis of hyperthyroidism about methimazole (Tapazole). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice.
- B. Report any fever or sore throat.
- C. Stop the medication if thyroid levels normalize.
- D. Avoid regular thyroid function Test s.
Correct Answer: B
Rationale: Fever or sore throat may indicate agranulocytosis, a serious methimazole side effect. Options A, C, and D are incorrect.
A client has just been admitted after sustaining a second-degree thermal injury to his right arm.
Which of the following nursing observations is MOST important to report to the doctor?
- A. Pain around the periphery of the injury.
- B. Gastric pH less than 6.0.
- C. Increased edema of the right arm.
- D. An elevated hematocrit.
Correct Answer: B
Rationale: Strategy: Determine how each assessment relates to burns. (1) expected findings in burn wound resolution (2) correct-decrease in gastric pH could indicate hypersecretion of hydrogen ions, predisposing factor to stress ulcer formation (3) expected findings in burn wound resolution (4) expected findings in burn wound resolution