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Questions 164

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Extract:


Question 1 of 5

The nurse is reinforcing teaching to the parents of a hospitalized 3-month-old about separation anxiety. The nurse notices that the parents still seem concerned about leaving the infant while they work. Which statement by one of the parents indicates that the teaching has been effective?

Correct Answer: C

Rationale: Infants at 3 months (
C) do not yet exhibit separation anxiety and cannot sense parental anxiety. Crying (
A), feeling abandoned (
B), and understanding return (
D) occur later in development.

Question 2 of 5

The nurse is talking with the parents of a 4-year-old client. The parents are concerned because the client was previously toilet trained but has started wetting the bed again while hospitalized. Which of the following responses would be most appropriate for the nurse to make?

Correct Answer: D

Rationale: Regression, such as bedwetting, is common in hospitalized children due to stress (
D). Reinforcing toileting behaviors (
A) may help but doesn't address the underlying cause. Fluid restriction (
B) is not appropriate without medical indication. Assuming misbehavior (
C) dismisses the emotional impact of hospitalization.

Question 3 of 5

An adult client was admitted for congestive heart failure today. An IV is running. The nurse enters the room and notes that the client is having increased difficulty breathing. Before calling the physician, what action should the nurse take?

Correct Answer: D

Rationale: Raising the head of the bed improves breathing in congestive heart failure by reducing pulmonary congestion. Increasing IV rate, supine positioning, or questioning delays intervention.

Extract:

Laboratory reference ranges
Sodium
136-145 mEq/L
(136-145 mmol/L)
Potassium
3.5-5 mEq/L
(3.5-5 mmol/L)
Creatinine
Male: 0.6–1.3 mg/dL
(53.0–114.9 μmol/L)

Female: 0.5-1.1 mg/dL
(44.2-97.2 μmol/L)
BUN
10-20 mg/dL
(3.6-7.1 mmol/L)


Question 4 of 5

The nurse has been made aware of laboratory test results for a client who is receiving continuous cardiac monitoring. The client is asymptomatic, and the cardiac monitor shows normal sinus rhythm. Which of the following is most likely an erroneous test result?

Correct Answer: C

Rationale: A potassium level of 7.0 mEq/L (
C) is life-threatening and would likely cause arrhythmias, inconsistent with normal sinus rhythm and asymptomatic status, suggesting an error. Elevated BUN (
A), sodium (
B), and creatinine (
D) are concerning but plausible in renal or dehydration issues without immediate cardiac effects.

Extract:


Question 5 of 5

An elderly client is admitted with an acute exacerbation of chronic obstructive pulmonary disease. Pulse oximetry is 84% on room air. The client is restless, has expiratory wheezing and a productive cough, and is using the accessory muscles to breathe. Which prescription should the nurse question?

Correct Answer: C

Rationale: Morphine (
C) can depress respiration in COPD, worsening hypoxia, and should be questioned. Albuterol (
A) relieves bronchospasm, methylprednisolone (
B) reduces inflammation, and oxygen (
D) addresses hypoxia, all appropriate for COPD exacerbation.

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