Nokea
The nurse is preparing to administer a sodium polystyrene sulfonate retention enema. Which explanation by the nurse best describes the purpose of this type of enema?
- A. A contrast medium is administered rectally to visualize the colon via x-ray'
- B. Bedridden clients receive this enema to stimulate defecation and relieve constipation.'
- C. This enema assists the large intestines in removing excess potassium from the body.'
- D. This enema is administered before bowel surgery to decrease bacteria in the colon.'
Correct Answer: C
Rationale: Sodium polystyrene sulfonate (C) removes excess potassium via the intestines, used in hyperkalemia. Other options describe unrelated procedures.
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During the immediate postoperative period after a colostomy, which stoma appearance requires the licensed practical nurse to contact the supervising registered nurse immediately?
- A. Brick red with slight moisture
- B. Dusky moderate edema
- C. Pink with slight oozing of blood
- D. Red with no stool produced
Correct Answer: B
Rationale: A dusky stoma (B) indicates ischemia, requiring immediate reporting. Brick red (A), pink with oozing (C), and no stool (D) are normal post-colostomy findings.
Laboratory reference ranges
Glucose (random) – newborn < 24 hours old
40-60 mg/dL
(2.2-3.3 mmol/L)
The nurse is monitoring a neonate 1 hour after spontaneous vaginal delivery. Which of the following are expected findings? Select all that apply.
- A. respirations of 56 breaths per minute
- B. capillary glucose of 60 mg/dL (3.3 mmol/L)
- C. holosystolic murmur auscultated at fourth intercostal space
- D. single transverse crease across palm of the hand
- E. white papules on bridge of the nose
Correct Answer: A, B, E
Rationale: Respirations of 56 (A), glucose of 60 mg/dL (B), and white papules (milia) (E) are normal in neonates. A holosystolic murmur (C) and single transverse crease (D) suggest congenital abnormalities.
A client just diagnosed with methicillin-resistant Staphylococcus aureus septic arthritis is receiving the first dose of IV vancomycin. Which finding is most concerning to the nurse?
- A. Diffuse muscle pain
- B. Flushing and pruritus
- C. Low blood pressure
- D. Wheezing and hives
Correct Answer: D
Rationale: Wheezing and hives (D) indicate a possible anaphylactic reaction, the most concerning finding. Muscle pain (A), flushing/pruritus (B), and low blood pressure (C) are less immediately life-threatening.
The nurse is reinforcing medication instructions for the parents of a child prescribed amoxicillin/clavulanate (liquid) twice a day for acute sinusitis. Which instructions are most important for the parents to remember? Select all that apply.
- A. Administer the medication with food if nausea or diarrhea develops
- B. Complete the medication course even if the child is better
- C. Rash is a normal, expected side effect
- D. Shake the medicine well before use
- E. Use a household spoon to measure the dose
Correct Answer: A, B, D
Rationale: Taking with food (A) reduces GI upset, completing the course (B) prevents resistance, and shaking well (D) ensures proper dosing. Rash (C) is not normal and requires evaluation, and household spoons (E) are inaccurate.
The nurse is caring for a client who has a Clostridioides difficile infection. Which of the following infection control precautions should the nurse implement? Select all that apply.
- A. Apply sterile gloves before providing client care.
- B. Request that the client be placed in a private room.
- C. Use an alcohol-based hand sanitizer for hand hygiene.
- D. Wear a single-use, protective gown when providing client care.
- E. Ensure surgical masks are worn by staff members who enter the client's room.
Correct Answer: B, D
Rationale: A private room (B) and protective gown (D) are required for contact precautions. Sterile gloves (A) are unnecessary, alcohol-based sanitizer (C) is ineffective against C. difficile spores, and surgical masks (E) are not required.