A nurse is assessing a 12-month-old infant who is brought to the clinic by the parents for a well-child visit. The nurse reviews the infant's health history and notes that the infant weighed 8 lb at birth. When assessing the infant's weight at this visit, the nurse would anticipate that the infant would weigh approximately how much at this time?

Answer and Explanation

The Correct Answer is C

A. 20 lbs: This is a plausible estimate. By 12 months, an infant's birth weight typically triples. Therefore, an 8 lb birth weight would approximately translate to 24 lbs at 12 months.

B. 32 lbs: This estimate is too high. If an infant's birth weight triples by 12 months, an 8 lb birth weight would not be expected to reach 32 lbs.

C. 24 lbs: An infant's weight usually triples by their first birthday. Therefore, an infant born weighing 8 lbs would be expected to weigh about 24 lbs at 12 months.

D. 16 lbs: This is an underestimate. An 8 lb infant would double their birth weight by about 4 to 6 months, and by 12 months, they would typically have tripled their birth weight to around 24 lbs.

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Correct Answer is B

Explanation

A. Document "impaired oxygenation" on the nursing care plan: While this may be appropriate based on assessment findings, it's premature to document without conducting a thorough assessment first.

B. Auscultate the chest for breath sounds: This is a critical component of assessing respiratory function, especially in a client with pneumonia, to identify abnormal breath sounds such as crackles or diminished breath sounds.

C. Collaborate with the client to form goals: Goal setting typically comes after assessment data is collected and analyzed.

D. Apply supplemental oxygen by face mask as needed: This action should be based on assessment findings indicating the need for oxygen therapy, not assumed without assessment.

A. Emergency B. Time-lapse C. Focused D. Initial

Correct Answer is A

Explanation

A. Emergency: This type of assessment is rapid and focuses on identifying and treating life-threatening conditions immediately, such as profuse bleeding from a stab wound.

B. Time-lapse: This assessment compares current client data to previous data to assess progress, which is not appropriate for an acute, life-threatening situation.

C. Focused: While this is a detailed assessment of a specific problem area, an emergency assessment is needed first for immediate threats to life.

D. Initial: This is a comprehensive assessment typically conducted when a client first enters a healthcare setting, but in an emergency, the focus shifts to immediate life-saving measures.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is conducting an assessment of a client that has been admitted to a medical unit in the hospital for treatment of pneumonia. Which action will the nurse take when conducting the respiratory assessment of this client?

Correct Answer is B

Explanation

A client who is bleeding profusely from a stab wound is brought to the emergency department. Which type of assessment is most appropriate for this client?

Correct Answer is A

Explanation

A nurse is receiving a change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process?

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

A nurse is preparing to examine the breasts of a client. In what position should the nurse place the client?

A nurse is preparing an older adult client for a physical examination the provider is about to perform. Which of the following actions should the nurse take?

A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first?

A nurse is conducting an interview with a client. Which example best demonstrates use of open-ended questions in an interview?

A nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take?