Strategy: All answers are implementations.

Determine the outcome of each

answer choice. Is it desired?
(1) should clean from the center of wound to the outside using sterile equipment
(2) dressings should be soaked before application
(3) correctif wet dressing touches skin it could cause skin breakdown
(4) should be removed dry so wound debris and necrotic tissue are removed with old
dressing
46. The nurse assesses the development of a three-month-old boy in the
well-baby clinic. Which of the following behaviors, if observed by the nurse,
would be UNEXPECTED?
1.
2.
3.
4.

The
The
The
The

boy
boy
boy
boy

holds his head erect when sitting on the examination table.

tries to grasp a toy just out of reach.
turns his head to try to locate a sound.
smiles spontaneously when he sees his mother.

Strategy: Picture the infant.

(1) expected at 3 months
(2) correctunexpected until 6 months of age
(3) expected at 3 months of age
(4) expected at 3 months of age
47. An older man is seen in the outpatient clinic for treatment of an acute
attack of gout. Which of the following nursing interventions would be MOST
beneficial in decreasing the clients pain during ambulation?
1.
2.
3.
4.

Perform passive range-of-motion exercises before walking.

Encourage partial weight bearing while ambulating.
Immobilize the extremity between activities.
Restrict the amount of time and the distance the man walks.

Strategy: All answers are implementations. Determine the outcome of each

answer choice. Is it desired?
(1) would aggravate pain
(2) correctwould relieve weight, pressure, and stress on affected leg, may use
walker
(3) would increase stiffness
(4) immobility would aggravate pain and inflammation
48. Which of the following observations best indicates to the nurse that a
paraplegic client can adequately carry out activities of daily living at home
after discharge?
1.
2.
3.
4.

The
The
The
The

client
client
client
client

can
can
can
can

shave himself and brush his teeth.

transfer himself into and out of his wheelchair.
maneuver his wheelchair without difficulty.
prepare his own well-balanced meals.