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Questions 163

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Question 1 of 5

The graduate nurse (GN) is reinforcing education on sitting on and standing up from a chair to a client with crutches. Which instruction by the GN would cause the supervising nurse to intervene?

Correct Answer: A

Rationale: Holding a crutch in each hand is incorrect as crutches should be placed together on the unaffected side or against a stable surface to free the hands for support when standing. Other instructions (B, C,
D) are correct for safe crutch use during sitting and standing.

Question 2 of 5

The doctor has ordered the insertion of an NG tube to determine the extent of gastric bleeding in a client with a gastric ulcer. To facilitate the insertion of the NG tube, the nurse should:

Correct Answer: C

Rationale: Asking the client to swallow helps guide the NG tube into the esophagus and stomach, facilitating insertion.

Question 3 of 5

Which client event would be considered an adverse event and would require completion of an incident/event/irregular occurrence/variance report? Select all that apply.

Correct Answer: B,D,E

Rationale: Adverse events requiring an incident report include worsening cellulitis due to missed antibiotics , a fall even without injury , and a significant delay in a STAT procedure . Late medication administration is a variance but not typically an adverse event unless harm occurs, and a seizure in a known epileptic is expected unless protocol was not followed.

Question 4 of 5

The nurse in the emergency department is caring for a newborn who has been vomiting. Which of the following findings may indicate that the newborn is experiencing a bowel obstruction?

Correct Answer: A

Rationale: Green-colored vomit in a newborn suggests bile, indicating a possible bowel obstruction like malrotation or volvulus. Occasional vomiting , blood streaks , and nasal vomit are less specific.

Question 5 of 5

The nurse is reviewing the medical record of a 4-year-old client with failure to thrive. Which of the following risk factors likely contribute to the client's condition? Select all that apply.

Correct Answer: B,C,E

Rationale: FTT risk factors include parental incarceration causing family stress, a history of anorexia nervosa affecting feeding practices, and food insecurity . Being the youngest or a working parent are not direct risks.

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