Nokea
The nurse judges that the parents of a newborn with imperforate anus know what a low defect is when they say that the rectum:
- A. Is below the abdominal rectus muscle
- B. Is above the abdominal rectus muscle
- C. Has descended through the puborectalis muscle
- D. Has ascended through the puborectalis muscle
Correct Answer: C
Rationale: A low defect in imperforate anus means the rectum has descended through the puborectalis muscle, indicating a less severe anomaly. Other options describe incorrect anatomical positions.
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A client with a diagnosis of gout is prescribed indomethacin. The nurse should instruct the client to:
- A. Take the medication with food to reduce stomach upset.
- B. Avoid drinking alcohol.
- C. Limit fluid intake.
- D. Take the medication at bedtime only.
Correct Answer: A,B
Rationale: Taking indomethacin with food reduces gastrointestinal upset, and avoiding alcohol prevents uric acid buildup.
A client has a prescription to begin short-term therapy with enoxaparin. The nurse explains to the client that this medication is being prescribed for which action?
- A. Dissolve urinary calculi
- B. Relieve migraine headaches
- C. Stop progression of multiple sclerosis
- D. Reduce the risk of deep vein thrombosis
Correct Answer: D
Rationale: Enoxaparin is an anticoagulant that is administered to prevent deep vein thrombosis and thromboembolism in selected clients at risk. It is not used to treat urinary calculi, migraine headaches, or multiple sclerosis.
A client with a history of type 1 diabetes is admitted with hypoglycemia. The nurse should administer which of the following if the client is conscious?
- A. Glucagon intramuscularly.
- B. 50% dextrose intravenously.
- C. Orange juice orally.
- D. Insulin subcutaneously.
Correct Answer: C
Rationale: Orange juice provides fast-acting carbohydrates to raise blood glucose in a conscious client with hypoglycemia.
A client with chronic renal failure is receiving hemodialysis. Which dietary restriction should the nurse emphasize?
- A. Low-protein diet.
- B. High-sodium diet.
- C. Low-potassium diet.
- D. High-calcium diet.
Correct Answer: C
Rationale: A low-potassium diet is critical in chronic renal failure to prevent hyperkalemia, which can cause cardiac complications.
Which neurological complication can occur when a vest restraint is too tight around the client's body?
- A. Strangulation
- B. Skin breakdown
- C. Skin pallor
- D. Numbness
Correct Answer: A
Rationale: A too-tight vest restraint can cause strangulation, a life-threatening complication, by restricting breathing or neck movement.