Nokea
The nurse is discussing activities for parallel play with the parents of a 2-year-old child. Which of the following activities are appropriate suggestions for this type of play? Select all that apply.
- A. Digging in a sandbox
- B. Finger painting
- C. Playing a board game
- D. Playing soccer
- E. Pushing toy cars
Correct Answer: A,B,E
Rationale: Parallel play involves independent activities side-by-side, like digging, painting, or pushing cars. Board games and soccer require cooperative play, unsuitable for 2-year-olds.
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The nurse is reinforcing discharge teaching for the parents of an infant with tetralogy of Fallot. Which of the following actions should the nurse include to reduce the incidence of hypercyanotic spells? Select all that apply.
- A. Dress the infant in warm clothing and blankets
- B. Encourage smaller, frequent feedings
- C. Intervene quickly to prevent the infant from crying excessively
- D. Promote a quiet period on waking in the morning
- E. Turn the infant frequently during sleep
Correct Answer: B,C,D
Rationale: Smaller feedings, preventing crying, and quiet periods reduce oxygen demand, minimizing hypercyanotic spells. Warm clothing and frequent turning do not directly prevent spells.
The client has an IV in place when he returns for surgery. While examining the IV site, the licensed practical nurse notices pallor, coolness, and edema. The nurse is aware that these are signs of:
- A. Infiltration
- B. Infection
- C. Thrombus formation
- D. Sclerosing of the vein
Correct Answer: A
Rationale: Pallor, coolness, and edema at an IV site indicate infiltration, where IV fluid leaks into surrounding tissue. Infection shows redness and warmth, thrombus formation may cause pain and redness, and sclerosing involves vein hardening, not edema.
A client asks the nurse about including her 2 and 12 year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?
- A. Focus on your sons' needs during the first days at home.
- B. Tell each child what he can do to help with the baby.
- C. Suggest that your husband spend more time with the boys.
- D. Ask the children what they would like to do for the newborn.
Correct Answer: A
Rationale: In an expanded family, it is important for parents to reassure older children that they are loved and as important as the newborn.
A client with a history of asthma is admitted with severe shortness of breath and cyanosis. Which finding would indicate that the client is experiencing status asthmaticus?
- A. Increased vocal fremitus
- B. Silent chest on auscultation
- C. Stridor during inspiration
- D. Rhonchi in bilateral lung fields
Correct Answer: B
Rationale: Silent chest on auscultation indicates severe airway obstruction with minimal air movement, a hallmark of status asthmaticus, requiring immediate intervention.
Laboratory Reference Ranges
Creatinine
Male: 0.6–1.3 mg/dL
(53–114.9 μmol/L)
Female: 0.5–1.2 mg/dL
(44.2–106.1 μmol/L)
The nurse is planning to assess 4 assigned clients. Which client situation is of greatest concern and warrants immediate assessment?
- A. Client scheduled for hemodialysis in an hour who has a serum creatinine level of 9.2 mg/dL (813 µmol/L) and refuses to take prescribed medications
- B. Client taking diphenhydramine for urticaria who reports difficulty urinating and increasing lower abdominal pain
- C. Client with an infected venous leg ulcer prescribed IV vancomycin who has a dressing saturated with yellow, foul-smelling drainage
- D. Client with an inguinal hernia who rates abdominal pain as 10 on a 0-10 scale and reports bloating, nausea, and vomiting
Correct Answer: D
Rationale: Severe pain (10/10) with bloating, nausea, and vomiting in an inguinal hernia suggests strangulation, a surgical emergency. High creatinine, urinary retention, and infected ulcers are urgent but less immediately life-threatening.