Nokea
The nurse is collecting data on a 2-day-old infant with suspected Hirschsprung disease. Which findings should the nurse anticipate? Select all that apply.
- A. Bright red bleeding from anus
- B. Distended abdomen
- C. Has not passed stool (meconium)
- D. Nonbilious vomiting
- E. Refuses to feed
Correct Answer: B,C,D
Rationale: Hirschsprung disease causes intestinal obstruction, leading to a distended abdomen, failure to pass meconium, and nonbilious vomiting. Bright red bleeding suggests other causes (e.g., fissure). Feeding refusal is less specific.
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The nurse practicing on a long-term care unit cares for a client with type 1 diabetes mellitus. Which action should the nurse assign to experienced unlicensed assistive personnel?
- A. Check the blood glucose before meals and report it to the nurse
- B. Instruct the client to cut toenails straight across and file any sharp edges
- C. Monitor the client for signs and symptoms of hypoglycemia
- D. Update the care plan to include client's preference for a nighttime diabetic snack
Correct Answer: A
Rationale: Checking blood glucose and reporting results is within UAP scope if trained. Teaching, monitoring for hypoglycemia, and updating care plans require nursing judgment and are outside UAP scope.
The nurse is observing a 3-year-old client for expected developmental milestones. It would require follow-up if the client cannot
- A. catch a ball at least 50% of the time
- B. copy a square with a pencil or crayon
- C. eat with a spoon
- D. hop on one foot
Correct Answer: B
Rationale: Copying a square is expected by age 4-5, not 3, indicating a fine motor delay requiring follow-up. Catching a ball, eating with a spoon, and hopping are age-appropriate or slightly advanced for a 3-year-old.
The nurse is caring for a client who has a prescription for insulin lispro 1 unit subcutaneously per 15 g of carbohydrates with each meal. The client's meal contains 75 g of carbohydrates. How many units of insulin lispro should the nurse administer to the client? Record your answer using a whole number.
Correct Answer: 5
Rationale: 75 g carbohydrates ÷ 15 g/unit = 5 units of insulin lispro.
A client with myxedema should be prescribed which diet?
- A. A diet low in fats
- B. A diet high in carbohydrates
- C. A diet high in sugars
- D. A diet low in salt
Correct Answer: B
Rationale: Myxedema (hypothyroidism) slows metabolism, so a high-carbohydrate diet provides energy to support metabolic needs.
A client with ascites due to cirrhosis has increasing shortness of breath and abdominal pain and is scheduled for paracentesis. Which of the following nursing actions should be implemented prior to the procedure? Select all that apply.
- A. Ensure that informed consent has been obtained
- B. Place the client in reverse Trendelenburg position
- C. Place the client on NPO status
- D. Request the client empty their bladder
- E. Take baseline vital signs and weight
Correct Answer: A,D,E
Rationale: Informed consent ensures understanding, emptying the bladder prevents injury during needle insertion, and baseline vital signs/weight monitor fluid shifts. Reverse Trendelenburg is inappropriate; upright positioning is typical. NPO status isn't required for paracentesis.