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Question 1 of 5

The nurse is caring for an ambulatory client who has a new order for continuous cardiac monitoring via a portable unit. It would require follow-up if the nurse

Correct Answer: D

Rationale: Placing electrodes on extremities (
D) is incorrect for cardiac monitoring, which requires chest placement. Verifying gel (
A), cleansing skin (
B), and clipping hair (
C) are appropriate.

Question 2 of 5

A 13-month-old child is admitted to the pediatric unit with diarrhea and vomiting. The mother tells the nurse that she is worried because her son does not yet walk. She says her other children walked at eight and nine months and asks what could be wrong with this child. How should the nurse respond?

Correct Answer: A

Rationale: Walking typically occurs between 9-18 months; at 13 months, not walking is within normal variation, reassuring the mother without dismissing concerns.

Question 3 of 5

The nurse is preparing to administer ear drops to a 5-year-old client. Which of the following actions should the nurse take?

Correct Answer: A

Rationale: Pulling the pinna upward and back (
A) straightens the ear canal in children over 3. Sitting with chin down (
B), touching the canal (
C), or cold drops (
D) are incorrect.

Question 4 of 5

The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure?

Correct Answer: C

Rationale: Encourage range of motion and ambulation. Mobility reduces the risk of deep vein thrombosis in the post-surgical client and the adult at risk due to other factors.

Question 5 of 5

The nurse has reinforced teaching with a client who has rheumatoid arthritis and is receiving methotrexate. Which of the following statements by the client would require follow-up?

Correct Answer: D

Rationale: Avoiding alcohol (
A), preventing pregnancy (
B), and avoiding crowds (
C) are correct. Avoiding folic acid (
D) is incorrect, as methotrexate often requires folic acid supplementation to reduce side effects.

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The nurse in a long-term care facility is caring for a client with major depressive disorder who is reporting difficulty sleeping. The client gets up during the night, paces the hallway, wrings the hands, and appears teary. Which of the following actions should the nurse take? Select all that apply.
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