Nokea
Which finding documented by the nurse is most indicative of the presence of a Curling's ulcer in the burned child?
- A. Absence of bowel sounds
- B. A positive hemoccult test
- C. An elevated hematocrit
- D. A distended abdomen
Correct Answer: B
Rationale: A positive hemoccult test indicates gastrointestinal bleeding, characteristic of a Curling's ulcer, a stress ulcer common in burn patients due to physiological stress and reduced mucosal protection.
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The most common side effect of tocolytic agents is:
- A. Vaginal bleeding.
- B. Abdominal pain.
- C. Nausea,vomiting.
- D. Palpitations.
- E. Oliguria.
Correct Answer: D
Rationale: Tocolytics such as beta-agonists commonly cause palpitations due to their sympathomimetic effects. Other side effects are less frequent or not primarily associated.
During preoperative preparation, which nursing action is most appropriate?
- A. Give analgesics.
- B. Give nothing by mouth (NPO).
- C. Give an enema.
- D. Apply heat to the abdomen.
Correct Answer: B
Rationale: Keeping the patient NPO prevents aspiration during surgery and reduces complications, as food in the stomach could interfere with anesthesia.
The nurse is caring for the infant in the neonatal ICU who has an umbilical artery catheter (UAC) in place. To monitor for and prevent complications with this catheter,which actions should be planned by the nurse? Select all that apply.
- A. Check the position marking on the catheter every shift.
- B. Position the tubing close to the infant’s lower limbs.
- C. Check for erythema or discoloration of the abdominal wall.
- D. Palpate for femoral,pedal,and tibial pulses every 2 to 4 hours.
- E. Reposition the catheter tubing every hour.
- F. Monitor blood glucose levels.
Correct Answer: A,C,D,F
Rationale: Check catheter position abdominal wall pulses every 2–4 hours and glucose levels to monitor for displacement bleeding perfusion issues or hypoglycemia. Keep tubing away from limbs and avoid frequent repositioning to reduce infection risk.
While preparing parents of a 2-day-old,bottle-feeding newborn for discharge the nurse recognizes the parents’ need for additional teaching about formula feeding. Which statement prompted the nurse’s conclusion?
- A. “We plan to clean our baby’s bottles in the dishwasher.”
- B. “Placing the formula in a bowl of warm water will warm it.”
- C. “We will put the bottle of unfinished formula in the refrigerator.”
- D. “Using our city tap water to mix the powdered formula is safe.”
Correct Answer: C
Rationale: Unfinished formula mixed with saliva should be discarded due to bacterial growth risk. Dishwasher cleaning warming in water and municipal tap water use are safe.
A primigravida is in second stage of labour for the past two hours. Fetal head is at +1 station. Inspite of effective uterine contractions,mother is unable to push as she is exhausted. What will be the next step in her management:
- A. Wait for another one hour.
- B. Give sedation to the mother.
- C. Shift her for emergency section.
- D. Instrumental delivery.
- E. Call the anaesthetist for regional anaesthesia.
Correct Answer: D
Rationale: Instrumental delivery (e.g. forceps or vacuum) is indicated for prolonged second stage due to maternal exhaustion provided the fetal head is engaged (+1 station). Cesarean section is considered if instrumental delivery is not feasible.