Nokea
A two-year-old is hospitalized with suspected intussusception. Which finding is associated with intussusception?
- A. Currant jelly stools
- B. Projectile vomiting
- C. Ribbonlike stools
- D. Palpable mass over the flank
Correct Answer: A
Rationale: Currant jelly stools (bloody, mucousy) are classic in intussusception due to intestinal ischemia. Vomiting and a palpable abdominal mass may occur, but stools and flank masses are less specific.
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The nurse is evaluating teaching effectiveness on a client with a gastrointestinal disorder prescribed a gluten-free diet. Which diet choice indicates that the client understands the instructions given?
- A. Steamed broccoli
- B. Wheat toast
- C. Chocolate chip cookie
- D. Bran cereal
Correct Answer: A
Rationale: Steamed broccoli is naturally gluten-free, indicating understanding of a gluten-free diet. Wheat toast (B), chocolate chip cookies (C), and bran cereal (D) contain gluten.
Prior to administering digoxin to a client with congestive heart failure, the nurse needs to assess:
- A. Respiratory rate for 1 minute
- B. Radial pulse for 1 minute
- C. Radial pulse for 2 minutes
- D. Apical pulse for 1 minute
Correct Answer: D
Rationale: Apical pulse should be measured for 1-minute prior to digoxin administration. Digoxin decreases the heart rate. Digoxin should be withheld if apical rates are <60 bpm or >120 bpm.
A client with benign prostatic hypertrophy has been started on Proscar (finasteride). The nurse's discharge teaching should include:
- A. Telling the client's wife not to touch the tablets
- B. Explaining that the medication should be taken with meals
- C. Telling the client that symptoms will improve in 1-2 weeks
- D. Instructing the client to take the medication at bedtime, to prevent nocturia
Correct Answer: A
Rationale: Finasteride tablets should not be handled by pregnant women due to the risk of fetal harm. Symptom improvement takes months, not weeks, and the medication can be taken with or without food or at any time.
A 74-year-old female client is 3 days postoperative. She has an indwelling catheter and has been progressing well. While the nurse is in the room, the client states, 'Oh dear, I feel like I have to urinate again!' Which of the following is the most appropriate initial nursing response?
- A. Assure her that this is most likely the result of bladder spasms.
- B. Check the collection bag and tubing to verify that the catheter is draining properly.
- C. Instruct her to do Kegel exercises to diminish the urge to void.
- D. Ask her if she has felt this way before.
Correct Answer: B
Rationale: The most frequent reason for an urge to void with an indwelling catheter is blocked tubing, so checking the catheter's patency is the best initial response.
The client is admitted with a diagnosis of gestational hypertension. Which vital sign change is most concerning?
- A. Blood pressure of 160/110
- B. Heart rate of 90 bpm
- C. Respiratory rate of 20 breaths per minute
- D. Temperature of 98.6°F
Correct Answer: A
Rationale: A blood pressure of 160/110 indicates severe gestational hypertension increasing the risk of complications like stroke or eclampsia and requires immediate intervention. The other vital signs are normal.