Nokea
Intussusception occurs when:
- A. Part of the intestine slides into another part of the intestine.
- B. The appendix ruptures.
- C. An ileostomy stoma retracts below the abdominal surface.
- D. Lungs are infiltrated.
Correct Answer: A
Rationale: Intussusception is a condition where one segment of the intestine telescopes into another, causing obstruction, most commonly in children.
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The nurse has provided an in-service presentation to ancillary staff about standard precautions on the birthing unit. The nurse determines that one of the staff members needs further instructions when the nurse observes which of the following?
- A. Use of protective goggles during a cesarean delivery.
- B. Placement of bloody sheets in a container designated for contaminated linens.
- C. Wearing of sterile gloves to bathe a newly delivered neonate at 1 hour of age.
- D. Disposal of used scalpel blades in a puncture-resistant container.
Correct Answer: C
Rationale: Sterile gloves are unnecessary for bathing a neonate; clean gloves suffice, indicating a need for further instruction on standard precautions.
When preparing a 3-year-old child for blood specimens to be drawn for laboratory testing, the nurse should?
- A. Explain the procedure in advance
- B. Explain why the blood needs to be drawn
- C. Use distraction techniques during the procedure
- D. Provide verbal explanations about what will occur
Correct Answer: C
Rationale: Distraction techniques are most effective for a 3-year-old during painful procedures like blood draws, as they have limited understanding of explanations. Simple preparation may help, but distraction is key.
Which of the following would demonstrate the correct technique for applying an elastic bandage to a leg?
- A. Increase tension with each successive turn of the bandage.
- B. Start at the distal end of the extremity and move toward the trunk.
- C. Secure the bandage with clips over the area of the inner thigh.
- D. Overlap each layer twice when wrapping.
Correct Answer: B
Rationale: Starting at the distal end and moving toward the trunk promotes venous return and prevents constriction.
The nurse should question which medication if prescribed for a client diagnosed with an inoperable ruptured intracranial aneurysm?
- A. Nicardipine
- B. Heparin sodium
- C. Docusate sodium
- D. Aminocaproic acid
Correct Answer: B
Rationale: The nurse should question a prescription for heparin sodium, which is an anticoagulant. This medication could place the client at risk for rebleeding. Nicardipine is a calcium channel-blocking agent that is useful in the management of vasospasm associated with cerebral hemorrhage. Docusate sodium is a stool softener, which helps prevent straining. Straining would raise intracranial pressure. Aminocaproic acid is an antifibrinolytic agent that prevents clot breakdown or dissolution. It may be prescribed after ruptured intracranial aneurysm and subarachnoid hemorrhage if surgery is delayed or contraindicated.
A client is scheduled for an intravenous pyelogram (IVP). Which of the following questions would be most important for the nurse to ask the client in preparation for the procedure?
- A. Have you ever had an IVP before?'
- B. Do you have any allergies to shellfish?'
- C. When was your last bowel movement?'
- D. Have you ever experienced urinary incontinence?'
Correct Answer: B
Rationale: Shellfish allergies may indicate a risk for contrast dye reactions, critical for IVP safety.