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Questions 157

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Question 1 of 5

The nurse assesses delayed gross motor development in a 3 year-old child. The inability of the child to do which action confirms this finding?

Correct Answer: A

Rationale: Stand on 1 foot. Balancing on one foot is expected by age 3, indicating gross motor delay if absent.

Question 2 of 5

The nurse performs diet teaching for a client with a spinal cord injury at S-3. Which of the following meals, if chosen by the client, would indicate to the nurse that teaching has been effective?

Correct Answer: B

Rationale: Spaghetti with meat sauce and green beans is high-fiber and low-fat, preventing constipation in spinal cord injury. Options A, C, and D are higher in fat or lower in fiber.

Question 3 of 5

The nurse is to start oxygen therapy via nasal cannula. Which action is correct?

Correct Answer: D

Rationale: Inserting the cannula 1 cm into the nostrils ensures proper oxygen delivery. High flow rates, petrolatum, or mask pre-oxygenation are incorrect.

Question 4 of 5

A client has a cataract removed from the left eye. Which of the following is an important nursing intervention in the immediate postoperative period?

Correct Answer: A

Rationale: Positioning on the right side with head elevation prevents pressure on the surgical eye, reducing complications. Options B, C, and D are incorrect.

Question 5 of 5

When caring for a client with myasthenia gravis, an important nursing consideration would be to

Correct Answer: D

Rationale: client has increased muscle fatigue, needs more assistance toward end of day

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