Nokea
Which nursing assessment finding indicates the presence of an inguinal hernia on a child?
- A. Reports of difficulty defecating
- B. Reports of a dribbling urinary stream
- C. Absence of the testes within the scrotum
- D. Painless groin swelling noticed when the child cries
Correct Answer: D
Rationale: Inguinal hernia is a common defect that may appear as a painless inguinal (groin) swelling when the child cries or strains. Option 1 is a symptom indicating a partial obstruction of the herniated loop of intestine. Option 2 describes a sign of phimosis, a narrowing or stenosis of the preputial opening of the foreskin. Option 3 describes cryptorchidism.
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A client undergoes transurethral resection of the prostate (TURP). Which solution should the nurse have available postoperatively for continuous bladder irrigation (CBI)?
- A. Sterile water
- B. Sterile normal saline
- C. Sterile Dakin's solution
- D. Sterile water with 5% dextrose
Correct Answer: B
Rationale: Continuous bladder irrigation is done after TURP using sterile normal saline, which is isotonic. Sterile water is not used because the solution could be absorbed systemically, precipitating hemolysis and possibly kidney failure. Dakin's solution contains hypochlorite and is used only for wound irrigation in selected circumstances. Solutions containing dextrose are not introduced into the bladder.
The client states that he has smoked three-fourths of a pack per day over the last 10 years. The nurse calculates that the client has a smoking history of how many pack-years?
Correct Answer: 7.5
Rationale: The standard method for quantifying smoking history is to multiply the number of packs smoked per day by the number of years of smoking. The number is recorded as the number of pack-years. The calculation for the number of pack-years for the client who has smoked three-fourths of a pack per day for 10 years is 0.75 pack × 10 years = 7.5 pack-years.
The nurse assesses the water seal chamber of a closed chest drainage system and notes fluctuations in the chamber. What intervention should the nurse implement?
- A. Unkinking the tubing
- B. Assessing for an air leak
- C. Documenting that the lung has reexpanded
- D. Documenting that the lung has not yet reexpanded
Correct Answer: D
Rationale: Fluctuations (tidaling) in the water seal chamber are normal during inhalation and exhalation until the lung reexpands and the client no longer requires chest drainage. If fluctuations are absent, it could indicate occlusion of the tubing or that the lung has reexpanded. Excessive bubbling in the water seal chamber indicates that an air leak is present.
A client is scheduled for computed tomography (CT) of the kidneys to rule out renal disease. Which should the nurse assess the client for before the procedure to best assure the client's safety?
- A. Allergies
- B. Familial renal disease
- C. Frequent antibiotic use
- D. Long-term diuretic therapy
Correct Answer: A
Rationale: The client undergoing any type of diagnostic testing involving possible dye administration should be questioned about allergies, specifically an allergy to shellfish or iodine. This is essential to identify the risk for potential allergic reaction to contrast dye, which may be used.
The nurse provides information to a client diagnosed with gastroesophageal reflux disease (GERD). What information should the nurse include when discussing foods that contribute to decreased lower esophageal sphincter (LES) pressure and thus worsen the condition? Select all that apply.
- A. Alcohol
- B. Fatty foods
- C. Citrus fruits
- D. Baked potatoes
- E. Caffeinated beverages
- F. Tomatoes and tomato products
Correct Answer: A,B,C,E,F
Rationale: GERD occurs as a result of the backward flow (reflux) of gastrointestinal contents into the esophagus. The most common cause of GERD is inappropriate relaxation of the LES, which allows the reflux of gastric contents into the esophagus and exposes the esophageal mucosa to gastric contents. Factors that influence the tone and contractility of the LES and lower LES pressure include alcohol; fatty foods; citrus fruits; caffeinated beverages such as coffee, tea, and cola; tomatoes and tomato products; chocolate; nicotine in cigarette smoke; calcium channel blockers; nitrates; anticholinergics; high levels of estrogen and progesterone; peppermint and spearmint; and nasogastric tube placement. Baked potatoes would not contribute to worsening the problem.