A nurse is collecting data from an 18-month-old toddler at a well-child visit.
Which of the following findings should the nurse report to the provider?
The toddler can remove her own socks.
The toddler has a security blanket.
The toddler can say four words.
The toddler throws a ball without falling.
The Correct Answer is C
c. The toddler can say four words.
Explanation:
The nurse should report to the provider that the toddler can say four words. At 18 months, a toddler typically has a vocabulary of about 6 to 20 words and is beginning to combine words into simple phrases. If the toddler is only able to say four words or has a delay in language development, it could be a cause for concern and warrant further evaluation.
The other options are age-appropriate developmental milestones for an 18-month-old toddler and do not require immediate reporting to the provider. The ability to remove socks, having a security blanket, and throwing a ball without falling are all examples of normal developmental skills for a toddler of this age.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
d. Remove the IV catheter.
Explanation:
The correct answer is d. Remove the IV catheter.
If the nurse realizes that the incorrect IV solution is infusing, it is essential to take prompt action to prevent harm to the client. Removing the IV catheter is the appropriate course of action to stop the infusion of the incorrect solution.
Option a, completing an incident report, may be necessary after the immediate situation has been addressed, but it should not be the nurse's first action. The priority is to stop the incorrect solution from infusing.
Option b, allowing the current solution to finish infusing and then changing the bag, is not the correct action. Continuing the infusion of the incorrect solution can potentially harm the client and must be stopped immediately.
Option c, documenting that an error occurred in the client's medical record, is important, but it should be done after taking immediate action to stop the incorrect solution from infusing. Documentation should include the details of the incident, any actions taken, and the client's response.
By promptly removing the IV catheter, the nurse stops the infusion of the incorrect solution and prevents further harm to the client. Afterward, the nurse should assess the client for any adverse effects, inform the appropriate healthcare providers, and follow the facility's policies and procedures for reporting incidents and documenting the error.
Correct Answer is D
Explanation
A client with heart failure should limit their sodium intake. Bottled salad dressings can be high in sodium, so replacing them with homemade vinegar and oil dressing can help reduce sodium intake.
The other options are not recommended for a client with heart failure who needs to limit their sodium intake.
a) Prepared frozen dinners are often high in sodium.
b) Adding salt when preparing a meal would increase sodium intake.
c) Imitation crab and lobster products (option can also be high in sodium.
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