Nokea
After surgery yesterday for gastroesophageal reflux, the nurse finds that the infant has somehow removed the nasogastric (NG) tube. What nursing action is most appropriate to perform at this time?
- A. Notify the practitioner.
- B. Insert the NG tube so feedings can be given.
- C. Replace the NG tube to maintain gastric decompression.
- D. Leave the NG tube out because it has probably been in long enough.
Correct Answer: A
Rationale: Notifying the practitioner is critical, as replacing an NG tube after upper GI surgery risks injury to the surgical site and requires surgical team evaluation. Inserting or replacing the tube independently or assuming it?s no longer needed bypasses necessary medical oversight.
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What clinical manifestation should be the most suggestive of acute appendicitis?
- A. Rebound tenderness
- B. Bright red or dark red rectal bleeding
- C. Abdominal pain that is relieved by eating
- D. Colicky, cramping, abdominal pain around the umbilicus
Correct Answer: D
Rationale: Colicky, periumbilical pain that becomes constant and may shift to the right lower quadrant is the hallmark of acute appendicitis. Rebound tenderness is unreliable and painful, bleeding is not typical, and pain relieved by eating is not associated with appendicitis.
A child with pyloric stenosis is having excessive vomiting. The nurse should assess for what potential complication?
- A. Hyperkalemia
- B. Hyperchloremia
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: D
Rationale: Excessive vomiting in pyloric stenosis leads to metabolic alkalosis due to loss of hydrogen ions. Potassium and chloride levels decrease, and acidosis is not typically associated with this condition.
A 2-year-old child has a chronic history of constipation and is brought to the clinic for evaluation. What should the therapeutic plan initially include?
- A. Bowel cleansing
- B. Dietary modification
- C. Structured toilet training
- D. Behavior modification
Correct Answer: A
Rationale: Initial treatment for chronic constipation involves bowel cleansing to empty the distended rectum, allowing it to return to normal size. Dietary modification follows, structured toilet training is unsuitable for a 2-year-old, and behavior modification is part of ongoing management.
The nurse is caring for a child admitted with acute abdominal pain and possible appendicitis. What intervention is appropriate to relieve the abdominal discomfort during the evaluation?
- A. Place in the Trendelenburg position.
- B. Apply moist heat to the abdomen.
- C. Allow the child to assume a position of comfort.
- D. Administer a saline enema to cleanse the bowel.
Correct Answer: C
Rationale: Allowing the child to assume a position of comfort, typically with legs flexed, eases abdominal pain. Trendelenburg position doesn?t help, heat or enemas increase perforation risk by stimulating bowel motility, and both are contraindicated in suspected appendicitis.
One of the major differences in clinical presentation between Crohn disease (CD) and ulcerative colitis (UC) is that UC is more likely to cause which clinical manifestation?
- A. Pain
- B. Rectal bleeding
- C. Perianal lesions
- D. Growth retardation
Correct Answer: B
Rationale: Rectal bleeding is more common in ulcerative colitis due to its exclusive involvement of the colon and rectum. Pain, perianal lesions, and growth retardation are more characteristic of Crohn disease, which can affect any part of the GI tract.