Nokea
The nurse assesses a child with intussusception. Which assessment findings require priority intervention?
- A. Abdominal rigidity with guarding
- B. Absence of tears in crying child with IV start
- C. Blood-streaked mucous stool in diaper
- D. Sausage-shaped right-sided mass on palpation
Correct Answer: A
Rationale: Abdominal rigidity with guarding suggests peritonitis or perforation, critical complications of intussusception requiring immediate surgical intervention.
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A client is receiving scheduled doses of carbidopa-levodopa. The nurse evaluates the medication as having the intended effect if which finding is noted?
- A. Improvement in short-term memory
- B. Improvement in spontaneous activity
- C. Reduction in number of visual hallucinations
- D. Reduction of dizziness with standing
Correct Answer: B
Rationale: Carbidopa-levodopa treats Parkinson's symptoms like bradykinesia, improving spontaneous activity, which is the primary therapeutic goal.
The nurse is suctioning the tracheostomy of an adult client. The recommended pressure setting is:
- A. 40-60 mm Hg
- B. 60-80 mm Hg
- C. 80-120 mm Hg
- D. 120-140 mm Hg
Correct Answer: C
Rationale: Suction pressure of 80-120 mm Hg is recommended for adult tracheostomy suctioning to effectively remove secretions without causing trauma.
During the initial home visit, a nurse is discussing the care of a client newly diagnosed with Alzheimer's disease with family members. Which of these interventions would be most helpful at this time?
- A. leave a book about relaxation techniques
- B. write out a daily exercise routine for them to assist the client to do
- C. list actions to improve the client's daily nutritional intake
- D. suggest communication strategies
Correct Answer: D
Rationale: Alzheimer's disease, a progressive chronic illness, greatly challenges caregivers. The nurse can be of greatest assistance in helping the family to use communication strategies to enhance their ability to relate to the client.
The parent of a 6-year-old calls the nurse and reports that the child was playing outside in the snow and the child's feet now appear red and swollen. What is the best response by the nurse?
- A. Bring the child to the health care provider's (HCP) office immediately.
- B. Give your child something warm to drink.
- C. Massage the child's feet gently until they warm up.
- D. Place the child's feet in warm water immediately.
Correct Answer: D
Rationale: Red and swollen feet suggest frostbite or cold injury. Immersing the feet in warm (not hot) water is the safest and most effective way to rewarm the tissue and prevent further damage.
An adult is receiving nasal oxygen at 6 L/min. The client asks the nurse why the oxygen is humidified. What should the nurse include when responding to the client?
- A. Humidifying oxygen helps to prevent fire.
- B. Humidity increases the concentration of oxygen.
- C. Humidity helps to keep the nasal passages from drying out.
- D. Humidity reduces the growth of organisms in the tubing.
Correct Answer: C
Rationale: Humidification prevents nasal mucosal drying and discomfort at higher oxygen flow rates like 6 L/min, not fire prevention, concentration increase, or bacterial reduction.