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Questions 163

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Question 1 of 5

The nurse is reviewing the medical record of a 4-year-old client with failure to thrive. Which of the following risk factors likely contribute to the client's condition? Select all that apply.

Correct Answer: B,C,E

Rationale: FTT risk factors include parental incarceration causing family stress, a history of anorexia nervosa affecting feeding practices, and food insecurity . Being the youngest or a working parent are not direct risks.

Question 2 of 5

A client is receiving oxygen therapy via a nasal cannula. When providing nursing care, which of the following interventions would be appropriate?

Correct Answer: B

Rationale: Inspect the nares and ears for skin breakdown. Oxygen therapy can cause drying of the nasal mucosa. Pressure from the tubing can cause skin irritation.

Question 3 of 5

A new graduate nurse is administering enoxaparin to a client. Which action indicates the need for further orientation by the nurse preceptor?

Correct Answer: B

Rationale: Ejecting the air bubble in an enoxaparin syringe is incorrect, as the bubble ensures complete dose delivery and prevents leakage. Other actions (A, C,
D) are correct for subcutaneous administration.

Question 4 of 5

An adult comes to the clinic with complaints of frequency and burning on urination. The nurse expects that what test will be ordered for the client?

Correct Answer: A

Rationale: Frequency and burning suggest urinary tract infection; a clean catch urine culture identifies the causative organism and antibiotic sensitivity. CBC, cystoscopy, or straining are less immediate.

Question 5 of 5

A client comes to the emergency department with diplopia and recent onset of nausea. Which statement by the client would indicate to the nurse that this is an emergency?

Correct Answer: D

Rationale: A severe headache described as the worst ever with diplopia and nausea suggests a possible subarachnoid hemorrhage or aneurysm, requiring emergency evaluation. Other statements (A, B,
C) are less specific.

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