Nokea
The nurse is monitoring a 12-month-old diagnosed with intussusception. Which findings should the nurse expect? Select all that apply.
- A. Palpable olive-shaped mass in epigastrium
- B. Palpable sausage-shaped mass in upper right quadrant
- C. Projectile vomiting containing blood
- D. Screaming and drawing the knees up to the chest
- E. Stool mixed with blood and mucus
Correct Answer: B,D,E
Rationale: Intussusception is characterized by a sausage-shaped mass, paroxysmal pain with knee-drawing, and 'currant jelly' stools.
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A nurse has been assigned to provide care to a client with suicidal ideation who is receiving treatment in an outpatient setting. The nurse develops a care plan and reviews it with the nurse preceptor before meeting with the client. Which proposed nursing action in the care plan requires intervention by the nurse preceptor?
- A. Assist the client in identifying the warning signs of a crisis
- B. Have the client write a list of people to contact for help and distraction
- C. Help the client develop ways of coping with suicidal thoughts
- D. Persuade the client to sign a contract promising not to attempt suicide
Correct Answer: D
Rationale: No-suicide contracts are not evidence-based and may create pressure rather than support coping strategies.
The client is unable to adequately bathe himself because he has dressings on his hands that cannot get wet. What is the most appropriate nursing diagnosis for this assessment finding?
- A. Risk for infection
- B. Deficient knowledge
- C. Acute pain related to specific illness or disease process
- D. Self-care deficit (bathing)
Correct Answer: D
Rationale: Inability to bathe due to hand dressings indicates a self-care deficit in bathing, the most specific nursing diagnosis.
A nurse is caring for a client following the delivery of a stillborn infant. Which of the following actions should the nurse take? Select all that apply.
- A. Ask the parents if they would like to help bathe the infant
- B. Discourage the parents from naming the infant
- C. Discuss the importance of organ donation with the parents
- D. Encourage the parents and family members to hold the infant
- E. Offer to obtain handprints, footprints, and photographs of the infant
Correct Answer: A,D,E
Rationale: Bathing, holding, and obtaining mementos support grieving. Naming is a personal choice, and organ donation discussions may be inappropriate at this time.
The nurse is preparing to administer an intermittent enteral feeding to a client who has a nasogastric tube and a gastric residual volume of 75 mL. Which of the following actions should the nurse take? Select all that apply.
- A. Administer the scheduled feeding as prescribed.
- B. Discard the aspirated residual in a biohazard container.
- C. Place the client in the high-Fowler position during the feeding.
- D. Flush the nasogastric tube before and after administering the feeding.
- E. Check the pH of the residual and notify the health care provider if the pH is > 5.
Correct Answer: A,C,D
Rationale: A residual of 75 mL is typically acceptable to proceed with feeding. High-Fowler position and flushing are standard. Residual is returned, not discarded, and pH >5 is not concerning.
A nurse has administered several blood transfusions over 3 days to a 12 year-old client with Thalassemia. What lab value should the nurse monitor closely during this therapy?
- A. Hemoglobin
- B. Red Blood Cell Indices
- C. Platelet count
- D. Neutrophil percent
Correct Answer: A
Rationale: Hemoglobin should be in a therapeutic range of approximately 10 g/dl (100 g). This level is low enough to foster the patient’s own erythropoiesis without enlarging the spleen.