Nokea
The practical nurse (PN) is collaborating with the registered nurse to conduct a developmental assessment of a 9-month-old client during a well-child visit. Which statement by the infant's parent should cause the PN concern?
- A. Our child needs help to grasp and bring teething toys to the mouth.
- B. Our child says 'mamama' to our dog.
- C. Our child screams when approached by unfamiliar people.
- D. Our child uses both hands for support to be able to sit upright.
Correct Answer: A
Rationale: By 9 months, infants should independently grasp objects. This indicates a potential fine motor delay requiring further evaluation.
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The client who is receiving enteral nutrition through a gastrostomy tube has had 4 diarrhea stools in the past 24 hours. The nurse should
- A. Review the medications the client is receiving
- B. Increase the formula infusion rate
- C. Increase the amount of water used to flush the tube
- D. Attach a rectal bag to protect the skin
Correct Answer: A
Rationale: Review the medications the client is receiving. Medications like antibiotics can cause diarrhea, requiring evaluation.
The nurse is caring for a client diagnosed with active pulmonary tuberculosis. Which elements of transmission-based precautions are required for the nurse when providing routine care? Select all that apply.
- A. Gown
- B. Goggles or face shield
- C. Hand hygiene
- D. N95 particulate respirator
- E. Surgical mask
Correct Answer: C,D
Rationale: Active pulmonary tuberculosis requires airborne precautions, including hand hygiene and an N95 respirator. A surgical mask is insufficient.
The nurse is talking with a client with acne vulgaris who has a new prescription for isotretinoin. Which of the following statements by the client would require follow-up?
- A. I will take an oral contraceptive and use condoms while taking isotretinoin.
- B. I need to wear sunscreen and sun-protective clothing while outdoors.
- C. I will take a vitamin A supplement daily while taking isotretinoin.
- D. I should avoid drinking alcohol while taking the medication.
Correct Answer: C
Rationale: Vitamin A supplements can increase the risk of toxicity with isotretinoin, which is a vitamin A derivative.
During a situation of pain management, which statement is a priority to consider for the ethical guidelines of the nurse?
- A. The client's self-report is the most important consideration
- B. Cultural sensitivity is fundamental to pain management
- C. Clients have the right to pain management
- D. Nurses should not prejudge a client's pain using their own values
Correct Answer: A
Rationale: The client's self-report is the most important consideration. Pain is a complex phenomenon that is perceived differently by each individual. Pain is whatever the client says it is. The other statements are correct but not the most important considerations.
The best choice for the child following a tonsillectomy is:
- A. Fruit punch
- B. Grape soda
- C. A banana Popsicle
- D. Ice cream
Correct Answer: C
Rationale: A banana Popsicle is soothing, cold, and non-irritating to the surgical site. Liquids like punch or soda may sting, and ice cream is dairy, which can increase mucus.