Passpoint Questions that are hard, weird, or specific

Before discharge from the hospital after a myocardial infarction, a client is taught to exercise by gradually increasing the distance walked. Which vital sign should the nurse teach the client to monitor to determine whether to increase or decrease the exercise level? a. body temperature b. respiratory rate c. blood pressure d. pulse rate

D. pulse rate Rationale: The client who is on a progressive exercise program at home after a myocardial infarction should be taught to monitor the pulse rate. The pulse rate can be expected to increase with exercise, but exercise should not be increased if the pulse rate increases more than about 25 bpm from baseline or exceeds 100 to 125 bpm. The client should also be taught to discontinue exercise if chest pain occurs.

A pediatric client has recently been diagnosed with asthma and is prescribed theophylline. What should the nurse include in the client's teaching concerning what to avoid when taking theophylline? Select all that apply. a. "You should avoid iced tea when taking theophylline." b. "You should avoid noodles when taking theophylline." c. "You should avoid chocolate when taking theophylline." d. "You should avoid ice cream when taking theophylline." e. "You should avoid caffeinated soft drinks when taking theophylline

a, c, e Rationale: Chocolate, some soft drinks, and iced tea contain caffeine and all caffeine should be avoided when taking theophylline. Noodles do not contain caffeine, so they are safe to consume while taking this medication. Some ice cream flavors may have caffeine, but clients do not necessarily need to avoid all ice cream.

The triage nurse in the pediatrician's office returns a call to a mother who is breastfeeding her 4-day-old infant. The mother is concerned about the yellow seedy stool that has developed since discharge home. What is the best reply by the nurse? a. "Soft and seedy unformed stools with each feeding are normal for this age and will continue through breastfeeding." b. "The stool will transition into a soft, brown, formed stool within a few days and is appropriate for breastfeeding." c. "This type of stool indicates the infant may have diarrhea and should be seen in the office today." d. "The stool results from the gassy food eaten by the mother. Refrain from eating these foods while breastfeeding."

a. "Soft and seedy unformed stools with each feeding are normal for this age and will continue through breastfeeding." Rationale: A soft seedy unformed stool is the norm for a 4-day-old infant. It may surprise the mother as it is a change from the meconium the infant had since birth. This stool is not diarrhea even though it has no form. There is no need for the infant to be seen for this. As long as the infant is breastfeeding, the stools will remain of this color and consistency. Brown and formed stool is common for an infant who is bottle-fed or after the breastfeeding infant has begun eating food.

Following a percutaneous transluminal coronary angioplasty, a client is monitored in the postprocedure unit. The client's heparin infusion was stopped 2 hours earlier. There is no evidence of bleeding or hematoma at the insertion site, and the pressure device is removed. The nurse should plan to remove the femoral sheath when the partial thromboplastin time (PTT) is: a. 50 seconds or less b. 75 seconds or less c. 100 seconds or less d. 125 seconds or less

a. 50 seconds or less Rationale:

Which instructions should the nurse give to a client after noting a white, cheese-like substance on the neonate's body creases? a. Allow it to remain on the skin. b. Brush it off with a dry washcloth. c. Clean the area with alcohol. d. Remove it with hand lotion.

a. Allow it to remain on the skin. Rationale: The white, cheese-like substance on the neonate's body creases is called vernix caseosa. Unless the vernix is stained with meconium or the mother has a bloodborne pathogen, it should be left on the skin because it serves as a protective coating that typically disappears within 24 hours of birth.Attempting to remove vernix caseosa (e.g., with lotion, alcohol, or a washcloth) will remove the protection and may damage the neonate's fragile skin.

A nurse refers a client with severe anxiety to a psychiatrist for medication evaluation. The physician is most likely to order which psychotropic drug regimen on a short-term basis? a. alprazolam, 0.25 mg orally every 8 hours b. chlorpromazine, 25 mg orally three times per day c. buspirone, 15 mg two times per day 200 mg orally twice per day d. benztropine, 2 mg orally twice per day

a. alprazolam, 0.25 mg orally every 8 hours Rationale: Alprazolam's antianxiety properties make it the most appropriate medication for this client. It should only be given very short term because of its addictive potential and the client should be weaned off of it. Benztropine is an antiparkinsonian agent used to control the extrapyramidal effects of antipsychotic agents such as chlorpromazine hydrochloride and thioridazine hydrochloride. Chlorpromazine is used to control the severe symptoms (hallucinations, thought disorders, and agitation) seen in clients with psychosis. Buspirone is an antianxiety agent but takes several weeks before it is effective in reducing anxiety. Thus it would not help this client who needs immediate assistance. Alprazolam provides immediate relief.

Small air bubbles adhering to the interior surface of the syringe might have which effect on parenteral administration? a. altered drug dose b. altered duration c. altered drug absorption d. altered onset of action

a. altered drug dose Rationale: Although not harmful to the client when injected, small air bubbles can actually change the dose of medication administered; therefore, the nurse should remove the air bubbles. Small air bubbles won't affect the drug's onset of action, duration, or absorption. Air bubbles may be helpful in some situations but should be added only after the dose of the drug has been withdrawn accurately. For example, with iron dextran, an air bubble and the Z-track method of injection help prevent permanent staining of the client's skin if the solution leaks into the subcutaneous tissue.

A client will receive IV midazolam hydrochloride during surgery. Which finding indicates a therapeutic effect? a. amnesia b. blurred vision c. nausea d. mild agitation

a. amnesia Rationale: Midazolam hydrochloride causes antegrade amnesia or decreased ability to remember events that occurred around the time of sedation. Nausea, mild agitation, and blurred vision are adverse effects of midazolam.

A client with schizophrenia who receives fluphenazine develops pseudoparkinsonism and akinesia. What drug should the nurse administer as ordered to minimize this client's extrapyramidal symptoms? a. benztropine b. dantrolene c. clonazepam d. diazepam

a. benztropine Rationale: Benztropine is an anticholinergic administered to reduce extrapyramidal adverse effects in the client taking antipsychotic drugs. It works by restoring the equilibrium between the neurotransmitters acetylcholine and dopamine in the central nervous system (CNS). Dantrolene, a hydantoin that reduces the catabolic processes, is administered to alleviate the symptoms of neuroleptic malignant syndrome, a potentially fatal adverse effect of antipsychotic drugs. Clonazepam, a benzodiazepine that depresses the CNS, is administered to control seizure activity. Diazepam, a benzodiazepine, is administered to reduce anxiety.

A nurse must monitor a client receiving chloramphenicol for adverse drug reactions. What is a toxic reaction to chloramphenicol? a. bone marrow suppression b. status epilepticus c. malignant hypertension d. lethal arrhythmias

a. bone marrow suppression Rationale: The most toxic reaction to chloramphenicol is bone marrow suppression. Chloramphenicol isn't known to cause lethal arrhythmias, malignant hypertension, or status epilepticus.

The nurse advises a mother with a 2-year-old child to avoid encouraging excessive milk consumption by the toddler because excess milk consumption can lead to which problem? a. iron deficiency b. biotin deficiency c. folate deficiency d. vitamin C deficiency

a. iron deficiency Rationale: Excessive milk consumption can lead to the displacement of iron-rich foods in the diet. This can result in iron deficiency anemia. Drinking excess milk will not cause vitamin C, biotin, or folate deficiencies.

Important teaching for a client receiving risperidone should include advising the client to: a. notify the physician if the client notices an increase in bruising. b. be sure to take the drug with a meal because it can severely irritate the stomach. c. discontinue the drug if the client gains weight. d. maintain a therapeutic level by doubling a dose if the client misses a dose.

a. notify the physician if the client notices an increase in bruising. Rationale: Bruising may indicate blood dyscrasias, so notifying the physician about increased bruising is very important. The client shouldn't double the drug dose. This drug doesn't irritate the stomach, and weight gain isn't an adverse effect of risperidone therapy.

A client with acute diarrhea is requesting an as-needed medication for loose, watery stools. After reviewing the physician's orders, which medication should the nurse administer? a. paregoric 5 ml P.O. b. chlorpheniramine polistirex and hydrocodone polistirex 25 ml P.O. c. morphine sulfate 1 mg I.V. d. alprazolam 0.25 mg P.O.

a. paregoric 5 ml P.O. Rationale: Paregoric helps decrease peristalsis and diarrhea caused by muscle spasms of the GI tract. Morphine sulfate, chlorpheniramine polistirex and hydrocodone polistirex, and alprazolam aren't indicated for diarrhea.

The client who has been hospitalized with pancreatitis does not drink alcohol because of religious convictions. The client becomes upset when the health care provider (HCP) persists in asking about alcohol intake. What should the nurse tell the client about the reason for these questions? a. "The health care provider must obtain the pertinent facts, regardless of religious beliefs." b. "There is a strong link between alcohol use and acute pancreatitis." c. "Alcohol intake can interfere with the tests used to diagnose pancreatitis." d. "Alcoholism is a major health problem, and all clients are questioned about alcohol intake."

b. "There is a strong link between alcohol use and acute pancreatitis." Rationale: Alcoholism is a major cause of acute pancreatitis in the United States and Canada. Because some clients are reluctant to discuss alcohol use, staff may inquire about it in several ways. Generally, alcohol intake does not interfere with the tests used to diagnose pancreatitis. Recent ingestion of large amounts of alcohol, however, may cause an increased serum amylase level. Large amounts of ethyl and methyl alcohol may produce an elevated urinary amylase concentration. All clients are asked about alcohol and drug use on hospital admission, but this information is especially pertinent for clients with pancreatitis. HCPs do need to seek facts, but this can be done while respecting the client's religious beliefs. Respecting religious beliefs is important in providing holistic client care.

During a prenatal visit, a nurse measures a client's fundal height at 19 cm. This measurement indicates that the fetus has reached approximately which gestational age? a. 24 weeks b. 19 weeks c. 28 weeks d. 12 weeks

b. 19 weeks Rationale: The fundal height measurement in centimeters equals the approximate gestational age in weeks, until week 32. Thus, fundal height at 12 weeks is 12 cm; at 24 weeks, 24 cm; and at 28 weeks, 28 cm.

An obese diabetic client has bilateral leg aching is to start a cardiac rehabilitation with an exercise program. Using which exercise equipment will be most helpful to the client? a. elliptical trainer b. stationary bicycle c. stair climber d. treadmill

b. Stationary Bicycle Rationale: The stationary bicycle is the most appropriate training modality because it is a non-weight-bearing exercise. The time that the individual exercises on the stationary bicycle is increased with improved functional capacity. The other exercise equipment requires exercising while standing.

A client is admitted to the oncology unit with an infection. It is suspected that the infection may be related to the vascular access device (VAD). The nurse should draw the blood cultures from which site? a. all lumens of the VAD b. a peripheral site and all lumens of the VAD c. the proximal lumen of the VAD only d. a peripheral site only

b. a peripheral site and all lumens of the VAD Rationale: When an infection is suspected from a VAD, blood cultures should be drawn peripherally and from all lumens of the VAD to determine the source of the infection. If the number of organisms is greater from the VAD than in the peripheral culture, the source is determined to be the VAD.

When measuring the fundal height of a primigravid client at 20 weeks' gestation, the nurse will locate the fundal height at which point? a. halfway between the client's symphysis pubis and umbilicus b. at about the level of the client's umbilicus c. near the client's xiphoid process and compressing the diaphragm d. between the client's umbilicus and xiphoid process

b. at about the level of the client's umbilicus Rationale: Measurement of the client's fundal height is a gross estimate of fetal gestational age. At 20 weeks' gestation, the fundal height should be at about the level of the client's umbilicus. The fundus typically is over the symphysis pubis at 12 weeks. A fundal height measurement between these two areas would suggest a fetus with a gestational age between 12 and 20 weeks. The fundal height increases approximately 1 cm/week after 20 weeks' gestation. The fundus typically reaches the xiphoid process at approximately 36 weeks' gestation. A fundal height between the umbilicus and the xiphoid process would suggest a fetus with a gestational age between 20 and 36 weeks. The fundus then commonly returns to about 4 cm below the xiphoid owing to lightening at 40 weeks. Additionally, pressure on the diaphragm occurs late in pregnancy. Therefore, a fundal height measurement near the xiphoid process with diaphragmatic compression suggests a fetus near the gestational age of 36 weeks or older.

When planning counseling sessions with adolescents, the nurse must incorporate measures to consider which abilities? a. representational thought b. capacity to deal with abstract possibilities c. conservation problem solving d. assimilation and accommodation

b. capacity to deal with abstract possibilities Rationale: The ability to deal with abstract possibilities develops during adolescence.Assimilation and accommodation are characteristics of an infant's sensorimotor development.Representational thought is associated with the preconceptual phase of development, from the ages of 2 to 4 years.Problems of conservation are part of concrete operations learned by children between ages 4 and 7 years.

A client is receiving methotrexate, 12 g/m2 I.V., to treat osteogenic carcinoma. During methotrexate therapy, the nurse expects the client to receive which other drug to protect normal cells? a. probenecid b. leucovorin (citrovorum factor or folinic acid) c. cytarabine d. thioguanine

b. leucovorin (citrovorum factor or folinic acid) Rationale: Leucovorin is administered with methotrexate to protect normal cells, which methotrexate could destroy if given alone. Probenecid should be avoided in clients receiving methotrexate because it reduces renal elimination of methotrexate, increasing the risk of methotrexate toxicity. Cytarabine and thioguanine aren't used to treat osteogenic carcinoma.

In which phase of postpartum psychological adaption would discharge teaching regarding infant care most likely be successful? a. taking in b. taking hold c. letting go d. resolution

b. taking hold Rationale: Beginning after completion of the taking-in phase, the taking-hold phase lasts about 4 to 5 weeks. At this time, the client is most ready to learn self-care and infant care skills.In the taking-in phase, the client focuses more on sleep.The letting-go phase is the final phase of postpartum psychological adaptation. This phase is characterized by readjustment, with the client viewing the infant as a separate being, refocusing on her relationship with her partner, and adjusting to the maternal role.Resolution is not considered an accepted phase of postpartum psychological adjustment.

An 11-year-old child is sent to the school nurse reporting difficulty reading the blackboard in the classroom. The nurse assesses that the child does not have difficulty reading a laptop screen or reading books. What is the best action by the nurse? a. Call the parents to discuss therapy for hyperopia. b. Try to determine the cause of the child's photophobia. c. Request that the child be screened for myopia. d. Inform the teacher that the child has strabismus.

c. Request that the child be screened for myopia. Rationale: Myopia is nearsightedness. The light rays focus at a point in front of the retina, and the client is able to see clearly objects directly in front but is unable to see at a distance.

The caregiver of a 2-month-old client calls stating that the client is "fussy and has a runny nose." The caregiver states that the client has been sleeping poorly at night and is not eating as well. Which of the following interventions will the nurse teach the caregiver? a. Have the caregiver make an appointment with the healthcare provider for antibiotics. b. Encourage the caregiver to administer aspirin as needed for fever. c. Use a bulb syringe to suction out the nasal passages. d. Give the client an over-the-counter cough-and-cold medicine.

c. Use a bulb syringe to suction out the nasal passages. Rationale: Children under 2 years of age should not take over-the-counter cough-and cold-medications. The symptoms that the caregiver is describing are for the common cold and antibiotics are not needed. Aspirin is contraindicated in children for the treatment of a fever due to the risk of Reye's syndrome. A bulb syringe to suction out the nasal passages of the client is an appropriate intervention.

The nurse observes that an older female has small to moderate, distended and tortuous veins running along the inner aspect of her lower legs. The nurse should: a. assess the client for foot ulcers. b. suggest the client contact her health care provider. c. encourage the client to avoid standing in one position for long periods of time. d. apply a half-leg pneumatic compression device.

c. encourage the client to avoid standing in one position for long periods of time. Rationale: The client has varicose veins, which are evident by the tortuous, distended veins where blood has pooled. To prevent pooling of the blood, the client should not stand in one place for long periods of time.It is not necessary to use compression devices, but the client could wear support hose if she stands for long periods of time.The client can consider cosmetic surgery to remove the distended veins, but there is no indication that the client should contact the health care provider at this point in time.The nurse can inspect the client's feet, but the client is not at risk for ulcers at this time.

The nurse is planning interventions for a school-aged child hospitalized with acute post-streptococcal glomerulonephritis in need of diversional activity. Which activity should the nurse expect to include? a. playing video games with a 4-year-old b. putting together a puzzle with mother c. playing a card game with someone the same age d. watching a movie with a younger brother

c. playing a card game with someone the same age Rationale: Generally, school-age children enjoy activities with their peers first, then family members, and lastly younger children. School-age children like to be busy but also to accomplish something. This helps to meet their task of industry versus inferiority, feeling good about what they are able to accomplish.

A physician prescribes several drugs for a client admitted to the emergency department with Laennec's cirrhosis. Which drug order should the nurse question? a. ketorolac b. vitamin K c. warfarin d. folic acid

c. warfarin Rationale:

The nurse is discharging a client at 35 weeks' gestation after a reactive nonstress test. The client asks the nurse how the fetus is doing. What is the nurse's best response? a. "The fetal heart rate dropped during the contractions, so we may need to induce you." b. "It is too early to tell, we will need to repeat the test in 2 weeks." c. "I'm sorry, your provider will have to inform you of the results of the test." d. "The fetal heart rate went up twice during the test, so your fetus is doing well.

d. "The fetal heart rate went up twice during the test, so your fetus is doing well. Rationale: During a nonstress test, an electronic fetal monitor provides a tracing of the fetal heart rate (FHR). Normally, the FHR accelerates with movement, indicating that the fetus has an intact autonomic nervous system that is not affected by uterine hypoxia. A reactive (normal) nonstress test with two accelerations going up 15 beats per minute and lasting 15 seconds in 20 minutes is a sign of fetal well-being. A nonstress test may be performed anytime after 32 weeks' gestation. Contractions are stimulated for a contraction stress test (CST); a positive CST is indicative of a fetus that may not handle the stress of labor well.

A primiparous client diagnosed with cystitis at 48 hours postpartum who is receiving intravenous ampicillin asks the nurse, "Can I still continue to breastfeed my baby?" What should the nurse tell the client? a. "You'll need to discontinue breastfeeding until the antibiotic therapy is stopped." b. "Alternate your breastfeeding with formula feeding to help you rest." c. "You will need to modify your technique by manually pumping your breasts." d. "You can continue to breastfeed as long as you want to do so."

d. "You can continue to breastfeed as long as you want to do so." Rationale: The client can continue to breastfeed as often as she desires. Continuation of breastfeeding is limited only by the client's discomfort or malaise. Antibiotics for treatment are chosen carefully so that they avoid affecting the neonate through breast milk. Drugs such as sulfonamides, nitrofurantoin, and cephalosporins usually are not prescribed for breastfeeding mothers. Manual pumping of the breasts is not necessary.

What is the most important information for the nurse to include when teaching a client about metronidazole? a. Urine may develop a greenish tinge while the client is taking this drug. b. Breathlessness and cough are common adverse effects. c. Heart palpitations may occur and should be immediately reported. d. Mixing this drug with alcohol causes severe nausea and vomiting.

d. Mixing this drug with alcohol causes severe nausea and vomiting. Rationale: When mixed with alcohol, metronidazole causes a disulfiram-like effect involving nausea, vomiting, and other unpleasant symptoms. Urine may turn reddish-brown, not greenish, from the drug. Cardiovascular or respiratory effects are not associated with this drug.

A pregnant client at 26 weeks gestation walks a moderate distance to get to her prenatal class. When she gets to the class, she starts experiencing uterine cramping with no backache or bloody show. She is quite concerned about the cramping and asks the nurse what is happening. The most appropriate response from the nurse would be to a. tell the client the pains could be lightening and to count the movements over the next hour. b. explain to the client she may be miscarrying. c. advise her to see her physician immediately for preterm labor. d. advise the client to rest and drink fluids.

d. advise the client to rest and drink fluids. Rationale: Braxton Hicks contractions are irregular, generally painless uterine cramping and occur intermittently throughout the pregnancy often beginning around 16 weeks gestation. The client should rest and drink fluids to alleviate Braxton Hicks contractions. Lightening describes the effects when the fetus settles into the pelvis and cramping is not a sign. The client does not have the symptoms of preterm labor or miscarriage.

A client with diabetes has been diagnosed with hypertension, and the health care provider has prescribed atenolol, a beta-blocker. When teaching the client about the drug, what should the nurse tell the client about how it may interact with the client's diabetes? Atenolol may cause: a. an increase in the incidence of ketoacidosis. b. .a decrease in the hypoglycemic effects of insulin. c. a decrease in the incidence of ketoacidosis. d. an increase in the hypoglycemic effects of insulin.

d. an increase in the hypoglycemic effects of insulin. Rationale: There is a direct interaction between the effects of insulin and those of beta blockers. The nurse must be aware that there is a potential for increased hypoglycemic effects of insulin when a beta blocker is added to the client's medication regimen. The client's blood sugar should be monitored. Ketoacidosis occurs in hyperglycemia. Although a decrease in the incidence of ketoacidosis could occur when a beta blocker is added, the direct result is an increase in the hypoglycemic effect of insulin.

A client is admitted in early active labor at 39 weeks' gestation with intact membranes. When assessing the fetal heart rate, the nurse locates the heart sounds above the client's umbilicus at midline. The nurse should further confirm that the fetus is lying in which position? a. transverse b. cephalic c. face d. frank breech

d. frank breech Rationale: When the fetus is in a breech position, the fetal heart rate most often is located above the umbilicus because the fetal heart is near the top of the mother's uterus. The heart of a fetus in the cephalic position is typically located on either the left or the right side of the client's uterus. Also, because the fetal heart typically is located in the lower portion of the mother's uterus, the sounds would be heard below the umbilicus. With a face presentation, fetal heart sounds are typically located on either the left or the right side of the client's uterus; in addition, because the fetal heart typically is located in the lower portion of the mother's uterus, the sounds would be heard below the umbilicus. When the fetus is in a transverse position, the fetal heart sounds typically would be located below the umbilicus and in the midline.

A nurse is performing a psychosocial assessment on a 14-year-old adolescent. Which response to the assessment questions is not typical during early adolescence? a. "I just want to go back to bed. When will this be done?" b. "If I sit through this whole appointment, what do I get out of it?" c. "I'm sorry for how I acted earlier. Let's finish these questions." d. "These questions are so stupid. When can I leave?"

c. "I'm sorry for how I acted earlier. Let's finish these questions." Rationale: Moodiness may occur often during early adolescence. Moodiness occurs due to immature cognitive control and emotional development. Essentially, early adolescent clients (age 10-14) have difficulty coping with emotions. These emotions are affected by the hormonal and maturing issues that occur during this time period. Anger and combativeness are more typical of middle adolescence. Cooperativeness typically occurs during late adolescence. Indications of depression are taken seriously and are not attributed to moody behaviors or statements.

The nurse is checking the blood sugar level of a pregnant client who is at 33 weeks' gestation. This client has had type 1 diabetes since she was 12 years old. Which fasting glucose value would indicate to the nurse that this client's disease is controlled? a. 136 mg/dl (7.6 mmol/L) b. 120 mg/dl (6.7 mmol/L) c. 85 mg/dl (4.7 mmol/L) d. 45 mg/dl (2.5 mmol/L)

c. 85 mg/dl (4.7 mmol/L) Rationale: The recommended fasting blood sugar level in a pregnant client with diabetes is 60 to 90 mg/dl (3.3 to 5.0 mmol/L). A fasting blood sugar level of 45 mg/dl (2.5 mmol/L) is low, and may result in symptoms of hypoglycemia. A blood sugar level below 120 mg/dl (6.7 mmol/L) is a recommended one-hour postprandial value. A blood sugar level above 136 mg/dl (7.6 mmol/L) in a pregnant client indicates hyperglycemia.

A nurse is teaching parents about the developmental milestones of an infant. Place the following developmental activities for an infant in order of occurrence by age from earliest to latest. All options must be used.

turning self from prone to supine turning self from supine to prone sitting alone crawling on hands and knees effectively using pincer grasp Rationale: Infants graduate from larger body movements to smaller. In general terms, infants typically roll over before sitting and crawl before they walk. More specifically, infants turn first from prone to supine, and then supine to prone by age 3 to 5 months. Sitting alone usually occurs at about age 6 to 7 months. Crawling occurs at around age 8 to 9 months. The use of pincer grasp usually occurs at around 10 to 12 months. They ages are general approximations.

What is the nurse's priority action when administering phenytoin to a client intravenously? a. withhold other anticonvulsants b. mix phenytoin with saline solution only c. administer rapidly d. use only dextrose solution when flushing the I.V. catheter

b. mix phenytoin with saline solution only Rationale:

A parent brings a child, age 3, to the clinic for an annual checkup. After plotting the child's height and weight on a pediatric growth chart, the nurse identifies which percentile range as normal? a. 25th to 75th percentile b. 50th to 100th percentile c. 10th to 100th percentile d. 5th to 95th percentile

d. 5th to 95th percentile Rationale: Height and weight measurements that fall between the 5th and 95th percentiles represent normal growth for most children. Children whose measurements fall outside this range require further evaluation.

When developing a teaching plan for a client taking hormonal contraceptives, a nurse should ensure that the client knows she must have which vital sign monitored regularly? a. Respirations b. Temperature c. Pulse d. Blood pressure

d. blood pressure Rationale: The incidence of hypertension is three to six times greater in clients using hormonal contraceptives than in women who don't use these drugs. Age and duration of the drug's use increase this incidence. Hormonal contraceptives don't directly affect pulse, respirations, or temperature.

A client is undergoing a complete physical examination as a requirement for college. When checking the client's respiratory status, the nurse observes respiratory excursion to help assess a. vocal sounds. b. lung vibrations. c. breath sounds. d. chest movements.

d. chest movements Rationale: The nurse observes respiratory excursion to help assess chest movements. Normally, thoracic expansion is symmetrical; unequal expansion may indicate pleural effusion, atelectasis, pulmonary embolus, or a rib or sternum fracture. The nurse assesses vocal sounds to evaluate air flow when checking for tactile fremitus; after asking the client to say the word "ninety-nine" the nurse palpates the vibrations transmitted from the bronchopulmonary system along the solid surfaces of the chest wall to the nurse's palms. The nurse assesses breath sounds during auscultation.