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Questions 164

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Question 1 of 5

A 9-month old is seen in the well child clinic. During the nursing assessment, the mother asks, 'Shouldn't he be making baby sounds by now? My friend's little boy is the same age and he is already saying dada.' The nurse reports the mother's concerns to the doctor for follow-up based on the knowledge that infants should be making rudimentary sounds by age:

Correct Answer: D

Rationale: Infants typically make cooing or babbling sounds by 6-8 months. Lack of sounds at 9 months warrants evaluation.

Question 2 of 5

A client on the oncology unit is to receive heparin sodium 5 units per kilogram of body weight by subcutaneous route every 4 hours. The client weighs 105.6 lbs. How many units should the client receive in a 24-hour period?

Correct Answer: C

Rationale: The client weighs 48 kg and should receive 5 units/kg, or 240 units every 4 hours. This would be 1440 units in 24 hours. The answers in A, B, and D are incorrect calculations.

Question 3 of 5

An adult is admitted for surgery today. Immediately after administering the preoperative medications of meperidine and atropine, the nurse notes that the operative permit has not been signed. Which action should the nurse take?

Correct Answer: D

Rationale: Preoperative medications like meperidine impair judgment, making consent invalid post-administration. Reporting to the physician to delay surgery ensures legal and ethical consent.

Question 4 of 5

A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make?

Correct Answer: B

Rationale: Left side-lying position is the optimal position for the client receiving rectal medications. Due to the position of the descending colon, left side-lying allows the medication to be inserted and move along the natural curve of the intestine and facilitates retention of the medication.

Question 5 of 5

An adult who had a cerebrovascular accident (CVA) with expressive aphasia has started saying some words. The client's family is quite upset because the words are mostly profanity. They tell the nurse that the client usually does not use profanity. How should the nurse respond to the family?

Correct Answer: B

Rationale: Profanity in early expressive aphasia post-CVA is common due to disinhibition in damaged brain areas; reassuring the family that other words will follow is appropriate.

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