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Questions 164

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Extract:

Laboratory Reference Ranges
Glucose (random)
71-200 mg/dL
(3.9-11.1 mmol/L)


Question 1 of 5

The student nurse completes a clinical rotation in the emergency department. The instructor knows the student is able to prioritize care appropriately when the student visits which client first?

Correct Answer: B

Rationale: Neck swelling and pain post-thyroidectomy suggest possible hematoma or airway compromise, a life-threatening emergency requiring immediate assessment. Other conditions, while serious, are less immediately critical.

Extract:


Question 2 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 3 of 5

A 6-month-old infant is being seen in the doctor's office. Which observation by the nurse should be brought to the physician's attention?

Correct Answer: B

Rationale: A 6-month-old should double birth weight (14 lb expected for 7 lb); 10 lb suggests poor growth, requiring evaluation. Other findings are developmentally normal.

Question 4 of 5

Based on knowledge of cultural diversity, the nurse knows that obtaining a CBC will be most distressing for the client who is:

Correct Answer: D

Rationale: Some Native American cultures believe blood removal weakens the body or spirit, making a CBC distressing. Other groups typically do not have this belief.

Question 5 of 5

A client was re-admitted to the hospital following a recent skull fracture. Which finding requires the nurse's immediate attention?

Correct Answer: A

Rationale: Lethargy. The level of consciousness or responsiveness is the most important measure of the client's rising intracranial pressure, requiring immediate attention.

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