Correct Answer: B

Rationale:
To assess for an S3 heart sound, the nurse should listen with the bell of the stethoscope. An S3 heart sound is often low-pitched and best heard with the bell.
Choice A is incorrect because switching to the diaphragm is not ideal for detecting low-pitched sounds like an S3.
Choice C is incorrect as the S3 heart sound is best heard over the apex of the heart, not the aortic area.
Choice D is incorrect because moving to the apical area is appropriate, but the nurse should specifically use the bell of the stethoscope to listen for S3 sounds.

Correct Answer: B

Rationale: The Modified Checklist for Autism in
Toddlers (M-CHAT) is specifically designed to screen for autism spectrum disorders in young children. It is appropriate for this child, given the signs of social and communication delays. The Peabody Picture Vocabulary Test (
Choice
A) assesses receptive vocabulary and may not capture the social and communication aspects seen in autism. The Wechsler Preschool and Primary Scale of Intelligence (
Choice
C) measures cognitive ability and may not address the social and communication delays. The Denver Developmental Screening Test (
Choice
D) is a broad developmental assessment tool, but the M-CHAT is more specific to screening for autism in this case.

Correct Answer: D

Rationale: After intravenous pyelography, it is crucial for the client to measure urine output in the next day to monitor for any potential complications, such as kidney issues. Promptly notifying the healthcare provider in case of decreased urine output is essential for timely intervention. While rest and hydration are important post-procedure, monitoring urine output takes precedence due to its direct correlation with potential complications.

Correct Answer: B

Rationale: When a client with multiple sclerosis is receiving intravenous methylprednisolone, the nurse's priority action is to monitor for signs of infection. Corticosteroids like methylprednisolone can suppress the immune system, increasing the risk of infection. Monitoring for signs of infection allows for early detection and prompt intervention. Monitoring blood glucose levels may be important in clients receiving corticosteroids for prolonged periods, but it is not the priority in this case. Encouraging increased oral fluid intake is generally beneficial but not the priority over monitoring for infection. Checking the client's temperature is important but not the priority action compared to monitoring for signs of infection.

Correct Answer: A

Rationale: The correct answer is to monitor the client's electrolyte levels. When a client is receiving IV fluids for dehydration, it is crucial to assess their electrolyte levels regularly. Dehydration can lead to imbalances in electrolytes, especially sodium and potassium, which are essential for maintaining fluid balance and proper organ function. Checking urine output (
Choice
B) is important but not as critical as monitoring electrolyte levels. Assessing skin turgor (
Choice
C) is an indirect method of assessing dehydration but does not provide specific information about electrolyte imbalances. Monitoring blood pressure (
Choice
D) is important but not the most critical assessment in this scenario as electrolyte imbalances can have a more direct impact on the client's condition.