A nurse is caring for a 30-month-old child. Which of the following activities should the nurse expect the child to participate in?

Playing with an imaginary friend

Playing with dress-up clothes

Playing with a large plastic truck

Playing with a jump rope

Answer and Explanation

The Correct Answer is C

A. This type of play usually begins around ages 3 to 4.

B.   While possible, this is more typical in slightly older children who engage in more complex forms of pretend play.
C.   At 30 months (2.5 years old), children are typically engaged in simple pretend play and enjoy playing with larger, more manipulable toys like plastic trucks. Their motor skills and cognitive development at this stage support this type of play.
D.   Coordination for jumping rope generally develops later, closer to school age.

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Correct Answer is B

Explanation

A. Sinus arrhythmia is a benign condition that does not typically require immediate assessment unless accompanied by other concerning symptoms.
B. Tachypnea in a client with a hip fracture may indicate a potential complication such as pulmonary embolism or respiratory compromise, requiring immediate assessment and intervention.
C. While weakness in the lower extremities in a client with epidural analgesia warrants assessment, it is not as urgent as assessing a client with new-onset tachypnea.
D. An HbA1c level of 7.2% in a client with diabetes mellitus, while slightly above the target range, does not require immediate assessment or intervention unless accompanied by acute symptoms of hyperglycemia.

A. Complete an incident report. B. Monitor the client's aPTT levels. C. Notify the risk manager. D. Check the client for indications of bleeding.

Correct Answer is D

Explanation

A. While completing an incident report is important for addressing the medication error and implementing corrective actions, the immediate priority is to assess the client's condition for signs of bleeding, which could be life-threatening.
B. Monitoring aPTT levels is important to assess the client's response to heparin therapy, but it does not address the immediate risk of bleeding from the overdose.
C. Notifying the risk manager is essential for reporting the medication error and implementing strategies to prevent future occurrences, but the nurse's first action should be to assess the client's condition for any indications of bleeding.
D. Administering a high dose of heparin increases the risk of bleeding, so the nurse should first assess the client for any signs or symptoms of bleeding, such as unexplained bruising, hematuria, or hypotension, to ensure timely intervention and prevent complication.

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A nurse is caring for a 30-month-old child. Which of the following activities should the nurse expect the child to participate in?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?

Correct Answer is B

Explanation

A nurse is caring for a client who received 50,000 units of IV heparin rather than the prescribed 5,000 units. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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