Nokea
Which developmental milestone puts the 4-month-old infant at greatest risk for injury?
- A. Switching objects from one hand to another
- B. Crawling
- C. Standing
- D. Rolling over
Correct Answer: D
Rationale: Rolling over at 4 months increases the risk of falling from elevated surfaces like changing tables, a common cause of injury.
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Which statement is true regarding balanced skeletal traction? Balanced skeletal traction:
- A. Utilizes a Steinman pin
- B. Requires that both legs be secured
- C. Utilizes Kirschner wires
- D. Is used primarily to heal the fractured hips
Correct Answer: A
Rationale: Balanced skeletal traction commonly uses a Steinman pin to stabilize fractures.
The nurse is assigned to work with the parents of a retarded child. Which of the following should the nurse include in the care plan for the parents?
- A. Interpret the grieving process for the parents.
- B. Discuss the reality of institutional placement.
- C. Assist the parents in making decisions and long-term plans for the child.
- D. Perform a family assessment to assist in the planning of intervention.
Correct Answer: D
Rationale: assessment, this will help the nurse to know where the family is in regard to grieving, coping, etc.
A nurse assessing a client charts his blood pressure as 134/86. The pulse pressure would be
- A. 48
- B. 86
- C. 220
- D. 96
Correct Answer: A
Rationale: Pulse pressure is calculated as systolic BP minus diastolic BP: 134 - 86 = 48 mmHg.
The charge nurse is formulating a discharge teaching plan for a client with mild preeclampsia. The nurse should give priority to:
- A. Teaching the client to report a nosebleed
- B. Instructing the client to maintain strict bed rest
- C. Telling the client to notify the doctor of pedal edema
- D. Advising the client to avoid sodium sources in the diet
Correct Answer: A
Rationale: A nosebleed may indicate worsening hypertension in preeclampsia, a critical symptom requiring immediate reporting.
The nurse receives an order for blood cultures and sensitivity for a client. Which statement is correct concerning this test?
- A. Preliminary test results are available 36 hours to allow the organisms time to grow.
- B. Growth and identification of the organism often takes 48 to 72 hours to complete.
- C. If the client has IV antibiotics infusing, stop the infusion before drawing blood cultures.
- D. If catheter sepsis is suspected, culturing the catheter tip is more accurate for identification.
Correct Answer: B
Rationale: Blood culture results typically take 48–72 hours for organism identification. Stopping antibiotics or culturing catheter tips is not standard practice.