Nokea
The nurse in the emergency department is caring for a newborn who has been vomiting. Which of the following findings may indicate that the newborn is experiencing a bowel obstruction?
- A. green colored vomit
- B. occasional vomiting since birth
- C. tiny streaks of blood in the vomit
- D. vomit coming through the nose
Correct Answer: A
Rationale: Green-colored vomit in a newborn suggests bile, indicating a possible bowel obstruction like malrotation or volvulus. Occasional vomiting , blood streaks , and nasal vomit are less specific.
You may also like to solve these questions
The client with herpes zoster will most likely have an order for which category of medication?
- A. Antibiotics
- B. Antipyretics
- C. Antivirals
- D. Anticoagulants
Correct Answer: C
Rationale: Herpes zoster, caused by the varicella-zoster virus, is treated with antivirals like acyclovir to reduce severity and duration. Antibiotics, antipyretics, and anticoagulants are not primary treatments.
The nurse reinforces discharge instructions to a client who was hospitalized for deep venous thrombosis that has now resolved. Which instructions should the nurse include to prevent reoccurrence? Select all that apply.
- A. Do not travel by car or airplane for at least 3-4 weeks
- B. Drink plenty of fluids daily and limit caffeine and alcohol intake
- C. Elevate legs on a footstool when sitting and dorsiflex the feet often
- D. Resume the walking or swimming exercise program as soon as possible after getting home
- E. Sit in a cross-legged yoga position for 5-10 minutes as this benefits circulation
Correct Answer: B,C,D
Rationale: To prevent DVT recurrence: stay hydrated to reduce blood viscosity, elevate legs and dorsiflex to promote venous return, and resume exercise to enhance circulation. Travel restrictions are not absolute post-resolution, and cross-legged sitting impedes venous flow.
It is the first day on the job for the newly hired unlicensed assistive personnel (UAP). Which of these illustrate appropriate assignment instructions for the licensed practical nurse (LPN) to give the UAP? Select all that apply.
- A. Elevate the right leg on two pillows.'
- B. Measure client for compression stockings.'
- C. Please let me know what the urine looks like.'
- D. Tell me what the client eats at lunch.'
- E. Verify wrist restraints are on correctly.'
Correct Answer: A,C,D
Rationale: Appropriate UAP tasks include elevating a leg , observing urine appearance , and reporting food intake . Measuring for stockings and verifying restraints require nursing judgment.
The nurse is caring for a client who had a transurethral resection of the prostate 12 hours ago and is receiving continuous bladder irrigation. The client reports lower abdominal pain rated as an 8 on a scale of 0 to 10. Which of the following actions would be a priority for the nurse to take?
- A. Administer morphine to the client.
- B. Verify when the client had the last flatus or bowel movement.
- C. Administer oxybutynin to the client.
- D. Verify the amount and characteristics of the client's urine output.
Correct Answer: D
Rationale: Severe abdominal pain post-TURP with bladder irrigation suggests possible catheter obstruction or clot formation. Verifying urine output and characteristics is the priority to ensure patency. Morphine , checking bowel movement , or oxybutynin are secondary.
A client has been admitted with a fractured femur and has been placed in skeletal traction. Which of the following nursing interventions should receive priority?
- A. Maintaining proper body alignment
- B. Frequent neurovascular assessments of the affected leg
- C. Inspection of pin sites for evidence of drainage or inflammation
- D. Applying an over-bed trapeze to assist the client with movement in bed
Correct Answer: B
Rationale: The most important activity for the nurse is to assess neurovascular status. Compartment syndrome is a serious complication of fractures. Prompt recognition of this neurovascular problem and early intervention may prevent permanent limb damage.