Question

A nurse is assessing the fontanels of an 8-month-old Infant. Which of the following findings should the nurse recognize as an expected finding?

Answer 1

Correct Answers:

The anterior fontanel is open.

Rationale :

👶The anterior fontanel normally remains open until about 12–18 months of age, making it expected in an 8-month-old infant.

🧠The posterior fontanel typically closes by 2–3 months, so it should not be open at this age.

⚖️Fontanels are not expected to be equal in size, as the anterior is normally larger than the posterior.

⚠️Molding is associated with birth process changes and should not be present at 8 months.

📌Core message

The anterior fontanel remains open in infancy, while the posterior closes early.

Answer 2

Correct Answers:

The client's total urinary output is 75 mL in the last 3 hr.

Rationale :

🩺Urinary output is a key indicator of renal perfusion and fluid status, especially in the postoperative period.

🚨An output of 75 mL over 3 hours is significantly low, indicating possible hypovolemia or decreased kidney perfusion, which requires immediate reporting.

⚠️Findings such as decreased bowel sounds are expected after abdominal surgery due to postoperative ileus.

🩹A scant amount of dark red drainage and moderate pain are expected and do not indicate acute complications.

📌Core message

Low urine output postoperatively signals possible renal hypoperfusion and requires immediate attention.

Answer 3

Correct Answers

Administer 0.9% sodium chloride 1000 mL IV at 150 mL/hr. [ Anticipated ]
Apply warm compresses to eyes. [ Unanticipated ]
Administer furosemide. [ Anticipated ]
Administer dexamethasone. [ Anticipated ]
Implement seizure precautions. [ Anticipated ]

Rationale :

🧠A pituitary adenoma can increase intracranial pressure, requiring interventions to reduce fluid and swelling.

💉IV fluids, diuretics, and corticosteroids help manage cerebral edema and fluid balance.

⚠️Seizure precautions are necessary due to neurological involvement and risk of seizures.

❌Warm compresses to the eyes are unrelated and do not address the underlying neurological condition.

📌Core message

Management of pituitary adenoma focuses on reducing intracranial pressure and preventing complications.

Answer 4

Correct Answers:

Prednisone

Rationale :

💊Prednisone is a corticosteroid that suppresses inflammation and immune response, which delays wound healing.

🧬It interferes with collagen synthesis and tissue repair, prolonging recovery.

⚠️Other medications listed do not significantly impair healing processes.

🩺Clients on steroids require monitoring for delayed healing and infection risk.

📌Core message

Corticosteroids like prednisone delay wound healing by suppressing inflammation.

Answer 5

Correct Answers:

Lorazepam .5 mg PO one tablet daily

Rationale :

💊Medication orders must be clear and unambiguous to ensure patient safety.

⚠️The notation “.5 mg” without a leading zero increases risk of dosage misinterpretation.

🧾Safe practice requires writing 0.5 mg to avoid medication errors.

🩺Other prescriptions are written correctly and do not pose clarity issues.

📌Core message

Always use a leading zero to prevent medication errors.

Answer 6

Correct Answers:

A 7-year-old child who is recovering from impetigo

Rationale :

🦠Acute poststreptococcal glomerulonephritis occurs after streptococcal infections, including skin infections like impetigo.

🧠The immune response leads to glomerular inflammation and kidney damage.

⚠️Other conditions listed are unrelated to streptococcal infection.

🩺Children recovering from strep infections should be monitored for renal complications.

📌Core message

Poststreptococcal complications can occur after skin or throat infections.

Answer 7

Correct Answers:

Change the feeding container and tubing every 24 hr.
Check gastric residuals every 4 hr.
Maintain the head of the client's bed at a 30° angle or higher.

Rationale :

🧴Changing feeding equipment every 24 hr reduces risk of infection and contamination.

🩺Checking gastric residuals ensures proper digestion and prevents aspiration.

🛏️Maintaining head elevation ≥30° reduces risk of aspiration pneumonia.

❌Formula should not be cold, and tube placement is not checked daily by x-ray.

📌Core message

Safe enteral feeding requires infection control, aspiration prevention, and monitoring tolerance.

Answer 8

Correct Answers:

Ventrogluteal

Rationale :

💉The ventrogluteal site is preferred for IM injections due to large muscle mass and fewer nerves.

🧠It reduces risk of injury to the sciatic nerve.

⚠️Other sites listed are not appropriate for intramuscular injections.

🩺This site ensures safe and effective medication delivery.

📌Core message

The ventrogluteal site is the safest for IM injections.

Answer 9

Correct Answers:

Denial

Rationale :

🧠Denial is the first stage in the Kubler-Ross stages of grief.

⚠️It involves refusal to accept reality of a terminal diagnosis.

📊Other options are not part of the recognized stages.

🩺Understanding stages helps provide appropriate emotional support.

📌Core message

Denial is the initial stage of grief in terminal illness.

Answer 10

Correct Answers:

Evaluate why the client was not ambulated

Rationale :

🧠The nurse must first assess the situation to understand why the task was not completed.

⚖️This ensures appropriate problem-solving and accountability.

⚠️Acting without evaluation may lead to repeated errors.

🩺Assessment is always the first step in the nursing process.

📌Core message

The nursing process begins with assessment before intervention.

intervention	Anticipated	Unanticipated
Administer 0.9% sodium chloride 1000 mL IV at 150 mL/hr.
Apply warm compresses to eyes.
Administer furosemide.
Administer dexamethasone.
Implement seizure precautions.

1 :
A nurse is assessing the fontanels of an 8-month-old Infant. Which of the following findings should the nurse recognize as an expected finding?

2 :
A nurse is assessing a client who is 6 hr postoperative following a total abdominal hysterectomy. Which of the following findings should the nurse report to the provider?

3 :
A nurse is caring for a client in a clinic.

Correct Answers

4 :
A nurse is reviewing the medication administration record of a client who has rheumatoid arthritis and is 1 day postoperative following a left total hip arthroplasty. Which of the following medications places the client at risk for delayed wound healing?

5 :
A nurse is transcribing new medication prescriptions for a group of clients. For which of the following prescriptions should the nurse contact the provider for clarification?

6 :
A nurse is caring for a group of children. Which of the following children should the nurse recognize as at risk for developing acute poststreptococcal glomerulonephritis?

7 :
A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following actions should the nurse take? (Select all that apply.)

8 :
A nurse is preparing to administer an intramuscular injection to a client. Which of the following injection sites should the nurse choose to utilize?

9 :
A nurse is caring for a client who has a new diagnosis of terminal advanced lung cancer. Which of the following is an expected stage of grief based on the stages of dying?

10 :
A charge nurse delegates to an assistive personnel (AP) the task of ambulating a client. At the end of the shift, the nurse discovers the client has not been ambulated. Which of the following actions should the nurse take first?

1 : A nurse is assessing the fontanels of an 8-month-old Infant. Which of the following findings should the nurse recognize as an expected finding?

2 : A nurse is assessing a client who is 6 hr postoperative following a total abdominal hysterectomy. Which of the following findings should the nurse report to the provider?

3 : A nurse is caring for a client in a clinic.

Correct Answers

4 : A nurse is reviewing the medication administration record of a client who has rheumatoid arthritis and is 1 day postoperative following a left total hip arthroplasty. Which of the following medications places the client at risk for delayed wound healing?

5 : A nurse is transcribing new medication prescriptions for a group of clients. For which of the following prescriptions should the nurse contact the provider for clarification?

6 : A nurse is caring for a group of children. Which of the following children should the nurse recognize as at risk for developing acute poststreptococcal glomerulonephritis?

7 : A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following actions should the nurse take? (Select all that apply.)

8 : A nurse is preparing to administer an intramuscular injection to a client. Which of the following injection sites should the nurse choose to utilize?

9 : A nurse is caring for a client who has a new diagnosis of terminal advanced lung cancer. Which of the following is an expected stage of grief based on the stages of dying?

10 : A charge nurse delegates to an assistive personnel (AP) the task of ambulating a client. At the end of the shift, the nurse discovers the client has not been ambulated. Which of the following actions should the nurse take first?

1 :
A nurse is assessing the fontanels of an 8-month-old Infant. Which of the following findings should the nurse recognize as an expected finding?

2 :
A nurse is assessing a client who is 6 hr postoperative following a total abdominal hysterectomy. Which of the following findings should the nurse report to the provider?

3 :
A nurse is caring for a client in a clinic.

4 :
A nurse is reviewing the medication administration record of a client who has rheumatoid arthritis and is 1 day postoperative following a left total hip arthroplasty. Which of the following medications places the client at risk for delayed wound healing?

5 :
A nurse is transcribing new medication prescriptions for a group of clients. For which of the following prescriptions should the nurse contact the provider for clarification?

6 :
A nurse is caring for a group of children. Which of the following children should the nurse recognize as at risk for developing acute poststreptococcal glomerulonephritis?

7 :
A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following actions should the nurse take? (Select all that apply.)

8 :
A nurse is preparing to administer an intramuscular injection to a client. Which of the following injection sites should the nurse choose to utilize?

9 :
A nurse is caring for a client who has a new diagnosis of terminal advanced lung cancer. Which of the following is an expected stage of grief based on the stages of dying?

10 :
A charge nurse delegates to an assistive personnel (AP) the task of ambulating a client. At the end of the shift, the nurse discovers the client has not been ambulated. Which of the following actions should the nurse take first?