Nokea
Which assessment finding for a 4-month-old infant would require further action by the nurse?
- A. The posterior fontanel is open.
- B. The infant has good head control when held upright.
- C. The infant is able to roll only from abdomen to back.
- D. The anterior fontanel is open and soft.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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When a patient is taking glucocorticoids and digoxin, which electrolyte should the nurse prioritize monitoring?
- A. Calcium
- B. Magnesium
- C. Sodium
- D. Potassium
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When preparing an adolescent for a lumbar puncture, which of the following actions should the nurse take?
- A. Place a cardiac monitor on the adolescent prior to the procedure
- B. Apply topical analgesic cream to the site one hour prior to the procedure
- C. Keep the adolescent in a semi-Fowler's position for 4 hours following the procedure
- D. Restrict fluids for 2 hours following the procedure
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A child returns from exploratory surgery following a gunshot wound to the abdomen. Which nursing intervention should be excluded from the plan of care?
- A. Immediate initiation of oral feedings
- B. Assessment of the surgical site
- C. Administration of opioid narcotics for pain management
- D. Visitation at the bedside
Correct Answer: A
Rationale: Immediate initiation of oral feedings is contraindicated post-abdominal surgery due to the risk of bowel complications such as paralytic ileus or anastomotic leak. Starting oral feedings immediately can increase the risk of these complications and hinder the healing process. It is crucial to wait until bowel function returns and the patient shows signs of tolerance before introducing oral feedings. Assessment of the surgical site, administration of opioid narcotics for pain management, and visitation at the bedside are essential components of postoperative care and should not be excluded.
A client has a new diagnosis of celiac disease. Which of the following clinical manifestations should the nurse expect?
- A. Steatorrhea
- B. Projectile vomiting
- C. Sunken abdomen
- D. Weight gain
Correct Answer: A
Rationale: Celiac disease is a condition where individuals are unable to digest gluten, leading to damage in the bowel cells and subsequent malabsorption. This malabsorption commonly presents with symptoms such as steatorrhea, which is characterized by foul-smelling, greasy, and bulky stools due to high fat content. Therefore, the nurse should expect steatorrhea as a clinical manifestation in clients with celiac disease.
The BEST car safety issues for a 3-year-child is
- A. vehicle seat belt
- B. rear-facing safety seat
- C. forward-facing car seat
- D. lap and shoulder seat belts
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.