A 2-year-old in the emergency department is suspected of hav...

A 2-year-old in the emergency department is suspected of having intussusception. Which assessment finding should the nurse expect?

A. Black, sticky stools
B. Greasy, foul-smelling stools
C. Stools mixed with blood and mucus
D. Thin, 'ribbon-like' stools

Correct Answer: C

Rationale: Intussusception causes intestinal obstruction, often leading to 'currant jelly' stools (blood and mucus). Black, sticky stools suggest upper GI bleeding. Greasy stools indicate malabsorption. Ribbon-like stools suggest rectal narrowing.

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Continuous bladder irrigation is prescribed for an adult who had bladder surgery; 1000 mL of irrigating solution was instilled in the last eight hours. The amount of drainage in the urine drainage bag for the last eight hours is 1700 mL. How much is the client's urine output for the last eight hours?

A. 270 mL
B. 700 mL
C. 1700 mL
D. 2799 mL

Correct Answer: B

Rationale: Urine output is calculated by subtracting instilled irrigation fluid (1000 mL) from total drainage (1700 mL), yielding 700 mL of actual urine.

The nurse is caring for a client who has a prescription for insulin lispro 1 unit subcutaneously per 15 g of carbohydrates with each meal. The client's meal contains 75 g of carbohydrates. How many units of insulin lispro should the nurse administer to the client? Record your answer using a whole number.

Correct Answer: 5

Rationale: 75 g carbohydrates ÷ 15 g/unit = 5 units of insulin lispro.

The nurse in the outpatient clinic is speaking with a client diagnosed with cerebral arteriovenous malformation. Which statement would be a priority for the nurse to report to the health care provider?

A. I got short of breath this morning when I worked out
B. I have cut down on smoking to Â½ pack per day
C. I haven't been feeling well, so I have been sleeping a lot.
D. I took an acetaminophen in the waiting room for this bad headache.

Correct Answer: D

Rationale: A bad headache in a client with cerebral arteriovenous malformation may indicate increased intracranial pressure or bleeding, requiring urgent reporting. Other symptoms are less specific and less immediately critical.

The unit secretary notifies the nurse that 4 clients called the nurses' station reporting pain. Which client should the nurse assess first?

A. Client who had a foot amputation today reporting left shoulder pain radiating down the arm
B. Client who has acute pancreatitis reporting severe, continuous, penetrating abdominal pain
C. Client who has multiple myeloma reporting deep pelvic pain after walking down the hall
D. Client who has sickle cell disease reporting severe pain in the arms and upper back

Correct Answer: A

Rationale: Shoulder pain radiating down the arm post-amputation suggests a possible cardiac event (e.g., angina), a life-threatening condition requiring immediate assessment. Other pains, while severe, are more likely related to known conditions.

The nurse is caring for a client with deep venous thrombosis of the lower extremity. Which of the following findings would the nurse expect to observe? Select all that apply.

A. dry, shiny, hairless skin on the affected extremity
B. warmth and redness of the affected extremity
C. reports of pain in the affected calf
D. edema of the affected extremity
E. cyanosis of the affected toes

Correct Answer: B,C,D

Rationale: DVT causes inflammation, leading to warmth, redness, pain, and edema in the affected extremity. Dry, shiny, hairless skin and cyanosis are more typical of arterial insufficiency, not DVT.