Nokea
A three-year-old boy was shown to have delays on the Denver Development Screening Test (DDST).
Which of the following responses by the nurse is BEST?
- A. Maybe he is just having a bad day. I'm sure he will do much better next time.
- B. The Test indicated a delay and we will have to investigate to learn more.
- C. What are your thoughts about how your child performed on the Test ?
- D. The results may not be accurate. Let's set up a time to reTest your child.
Correct Answer: C
Rationale: Strategy: 'BEST' indicates that fine discrimination is required. The topic of the questions is unstated. Determine topic by reading the answer choices. (1) nontherapeutic, false reassurance (2) factual but closed communication (3) correct-open-ended, encourages discussion (4) doesn't encourage discussion of concerns
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When suctioning a client's tracheostomy, the nurse should instill saline in order to
- A. decrease the client's discomfort
- B. reduce viscosity of secretions
- C. prevent client aspiration
- D. remove a mucus plug
Correct Answer: D
Rationale: remove a mucus plug. While no longer recommended for routine suctioning, saline may thin and loosen viscous secretions that are very difficult to move, perhaps making them easier to suction.
The nurse is caring for a client with a history of eating disorders.
- A. Which client statement indicates a need for further teaching about anorexia nervosa?
- B. I need to gain weight slowly to stay healthy.'
- C. I can stop dieting once I reach my goal weight.'
- D. I should eat balanced meals regularly.'
- E. I need support to change my eating habits.'
Correct Answer: B
Rationale: Stating that dieting can stop at a goal weight suggests a misunderstanding, as anorexia requires ongoing nutritional and psychological management. Slow weight gain, balanced meals, and support are correct.
The nurse is caring for a client who is receiving a continuous IV infusion of insulin for diabetic ketoacidosis. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood glucose of 200 mg/dL.
- B. Potassium of 3.0 mEq/L.
- C. pH of 7.30.
- D. Sodium of 135 mEq/L.
Correct Answer: B
Rationale: Hypokalemia (potassium 3.0 mEq/L) is a serious complication in diabetic ketoacidosis treatment, as insulin drives potassium into cells, risking arrhythmias. Options A, C, and D are less urgent: glucose 200 mg/dL is improving, pH 7.30 is near normal, and sodium 135 mEq/L is normal.
The nurse is caring for a client who is receiving IV fluids at 125 mL/hour. Which of the following findings should the nurse report immediately?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 80 bpm.
- C. Shortness of breath and crackles.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: Shortness of breath and crackles suggest fluid overload, a serious complication. Options A, B, and D are normal.
The nurse is to move a client up in bed without any help. Where should the nurse place the client's pillow?
- A. At the bottom of the bed
- B. On the bedside stand
- C. At the head of the bed
- D. Under the client's head
Correct Answer: C
Rationale: Placing the pillow at the head of the bed supports the client's head after moving up, ensuring comfort and proper positioning.