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Questions 164

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Question 1 of 5

The nurse is observing a 3-year-old client for expected developmental milestones. It would require follow-up if the client cannot

Correct Answer: B

Rationale: Copying a square is expected by age 4-5, not 3, indicating a fine motor delay requiring follow-up. Catching a ball, eating with a spoon, and hopping are age-appropriate or slightly advanced for a 3-year-old.

Question 2 of 5

A client with type 2 diabetes, coronary artery disease, and peripheral arterial disease developed hospital-acquired pneumonia (HAP) and has been receiving intravenous (IV) antibiotics for 4 days. Which parameter monitored by the nurse best indicates the effectiveness of treatment?

Correct Answer: D

Rationale: A decreasing WBC count indicates resolving infection, as HAP elevates WBCs. Sputum color is unreliable, lung sounds improve later, and oxygen saturation reflects oxygenation, not infection status.

Question 3 of 5

The nurse's neighbor has a total cholesterol of 450 mg/dL. The neighbor asks the nurse what this means. What should the nurse include when responding?

Correct Answer: C

Rationale: A cholesterol level of 450 mg/dL is significantly elevated, increasing cardiovascular risk, requiring medical consultation.

Question 4 of 5

The charge nurse is observing the nurse apply a condom catheter for a client who is uncircumcised. The charge nurse should intervene if the nurse

Correct Answer: B

Rationale: Retracting the foreskin before applying a condom catheter risks paraphimosis if not repositioned afterward, requiring intervention. Other actions are correct: attaching tubing, assessing skin, and leaving space prevent complications.

Question 5 of 5

The nurse is caring for a client with trigeminal neuralgia (tic douloureux). To assist the client with nutrition needs, the nurse should

Correct Answer: A

Rationale: Offer small meals of high calorie soft food. High-calorie soft foods minimize chewing, providing nourishment with less pain.

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