Nokea
A 30-year-old client is hospitalized with a fractured femur, which is being treated with skeletal traction. He states that he has not had a bowel movement for 2 days. Which of the following interventions is most appropriate at this time?
- A. Administer a tap water enema.
- B. Place the client on the bedpan every 2 to 3 hours.
- C. Increase the client's fluid intake to 3,000 mL/day.
- D. Perform range-of-motion movements to all extremities.
Correct Answer: C
Rationale: Increasing fluid intake promotes bowel motility, addressing constipation in a client immobilized by traction.
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A 6-month-old infant is admitted with a diagnosis of bacterial meningitis. The nurse should expect to observe which of the following symptoms?
- A. Positive Babinski reflex.
- B. High-pitched cry.
- C. Hypothermia.
- D. Kernig's sign.
Correct Answer: B
Rationale: A high-pitched cry is a common symptom of bacterial meningitis in infants, indicating neurological irritation.
The nurse is assessing a newborn 12 hours after birth. Which of the following findings should be reported to the physician?
- A. Heart rate of 120 beats per minute.
- B. Respiratory rate of 40 breaths per minute.
- C. Acrocyanosis.
- D. Capillary refill of 5 seconds.
Correct Answer: D
Rationale: Capillary refill of 5 seconds indicates poor perfusion in a newborn, requiring physician notification.
A newborn infant is diagnosed with imperforate anus. Which description of this disorder should the nurse provide to the parents?
- A. The presence of fecal incontinence
- B. Incomplete development of the anus
- C. The infrequent and difficult passage of dry stools
- D. Invagination of a section of the intestine into the distal bowel
Correct Answer: B
Rationale: Imperforate anus (anal atresia, anal agenesis) is the incomplete development or absence of the anus in its normal position in the perineum. Option 1 describes encopresis. Encopresis generally affects preschool and school-age children. Option 3 describes constipation. Constipation can affect any child at any time, although it peaks at age 2 to 3 years. Option 4 describes intussusception.
Your client has an allergy to both penicillin and latex. Which of these pathophysiological facts should you apply when you are providing to this client?
- A. The sensitizing dose of penicillin can lead to anaphylaxis.
- B. The second dose of penicillin can lead to distributive shock.
- C. You should be aware of the fact that about 10% of the population has an allergy to both penicillin and latex.
- D. You should be aware of the fact that about 20% of the population has an allergy to both penicillin and latex.
Correct Answer: A
Rationale: A sensitizing dose of penicillin can lead to anaphylaxis , a life-threatening allergic reaction, which is critical to consider when caring for a client with a penicillin allergy. The prevalence of dual allergies (C, D) is not accurate, and distributive shock is not specific to a second dose.
A primiparous client develops uterine atony and postpartum hemorrhage 1 hour after a vaginal delivery. The physician has ordered I.M. prostagland in F₂a. After administration of the medication, the nurse should observe the client for which of the following?
- A. Tachycardia
- B. Hypotension
- C. Constipation
- D. Fever
Correct Answer: A
Rationale: Prostaglandin-F2α can cause tachycardia as a side effect due to its stimulatory effects on smooth muscle. Hypotension, constipation, and fever are less commonly associated.