Nokea
A postoperative client is having difficulty voiding. Palpation of the bladder indicates that the bladder is full. What should the nurse do initially?
- A. Ask the physician for a catheterization order
- B. Pour water over the client's perineum
- C. Encourage the client to take deep breaths
- D. Administer pain medication
Correct Answer: B
Rationale: Pouring water over the perineum stimulates the micturition reflex, aiding voiding non-invasively. Catheterization, breathing, or pain medication are secondary.
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Diagnosis-related groups (DRGs) provide data to
- A. Identify clients who have specific medical diagnoses
- B. Identify findings related to a medical diagnosis
- C. Determine reimbursement for a medical diagnosis
- D. Implement nursing care based on case management protocol
Correct Answer: C
Rationale: Determine reimbursement for a medical diagnosis. DRGs are the basis of prospective payment plans for reimbursement for Medicare clients.
Which statement by a parent would alert the nurse to assess for iron deficiency anemia in a 14 month-old child?
- A. I know there is a problem since my baby is always constipated.
- B. My child doesn't like many fruits and vegetables, but she really loves her milk.
- C. My child is not eating as much as she did 4 months ago.
- D. My child doesn't drink a whole glass of juice or water at 1 time.
Correct Answer: B
Rationale: My child doesn't like many fruits and vegetables, but she really loves her milk. Excessive milk intake can displace iron-rich foods, leading to iron deficiency anemia.
While planning care for a 2 year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior?
- A. Strange bed and surroundings
- B. Separation from parents
- C. Presence of other toddlers
- D. Unfamiliar toys and games
Correct Answer: B
Rationale: Separation from parents. Separation anxiety is the greatest stress for a toddler during hospitalization.
The nurse is caring for a client who had an endoscopic procedure yesterday to stop upper gastrointestinal bleeding and who started a clear liquid diet today. Which of the following foods would be appropriate to offer to this client? Select all that apply.
- A. Apple juice
- B. Chicken broth
- C. Cranberry juice
- D. Cream of chicken soup
- E. Unsweetened tea
- F. Vanilla ice cream
Correct Answer: A, B, C, E
Rationale: Clear liquids include apple juice (A), chicken broth (B), cranberry juice (C), and unsweetened tea (E). Cream of chicken soup (D) and ice cream (F) are not clear liquids.
A child on the playground is experiencing an anaphylactic reaction. The school nurse arrives with an EpiPen. The weather is cold and the child is wearing several layers of clothing. How should the nurse proceed with the EpiPen?
- A. Inject into the upper arm where the sleeve can be pulled up
- B. Inject into the most accessible vein
- C. Inject through the clothing into thigh and hold in place for 10 seconds
- D. Take the child inside, remove excess clothing, and inject into the thigh
Correct Answer: C
Rationale: Injecting through clothing into the thigh (C) ensures rapid administration during anaphylaxis. Arm injection (A) is incorrect, IV injection (B) is not for EpiPens, and delaying to remove clothing (D) is dangerous.