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Questions 227

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Extract:

The maximum safe height at which the container of fluid can be held when administering an enema is:


Question 1 of 5

The maximum safe height at which the container of fluid can be held when administering an enema is:

Correct Answer: C

Rationale: 45 cm (18 inches) ensures safe pressure to avoid bowel injury during an enema.

Extract:


Question 2 of 5

A nurse is caring for a patient who has recently been diagnosed with fibromyalgia and COPD. Which of the following tasks should the nurse delegate to a nursing assistant?

Correct Answer: A

Rationale: Nursing assistants should be competent on all transfers.

Question 3 of 5

The 5-minute Apgar of a baby delivered by C-section is recorded as 9. The most likely reason for this score is:

Correct Answer: C

Rationale: Cyanosis of the hands and feet (acrocyanosis) is common in newborns and may result in a 1-point deduction from a perfect Apgar score of 10.

Extract:

When reviewing the immunization schedule for a 12-month-old, the nurse would expect that the infant had been previously immunized against:


Question 4 of 5

Pertussis, tetanus, polio, and measles.

Correct Answer: B

Rationale: The recommended immunization schedule for infants includes administration of the combined diphtheria, pertussis, and tetanus vaccine and the trivalent oral polio virus at ages 2, 4, and 6 months.

Extract:


Question 5 of 5

A client who is immobilized secondary to traction is complaining of constipation. Which of the following medications should the nurse expect to be ordered?

Correct Answer: D

Rationale: Colace, a stool softener, is appropriate for constipation in immobilized clients, as it promotes softer stools without systemic effects. The other options are NSAIDs, not laxatives. Basic Care and Comfort

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