Nokea
Which of these parents' comments about a newborn would most likely reveal an initial finding of a suspected pyloric stenosis?
- A. I noticed a little lump a little above the belly button.
- B. The baby seems hungry all the time.
- C. Mild vomiting turned into vomiting that shot across the room.
- D. We notice irritation and spitting up immediately after feedings.
Correct Answer: C
Rationale: Mild vomiting turned into vomiting that shot across the room. Projectile vomiting is a hallmark of pyloric stenosis.
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The nurse is preparing a client for a kidney-ureter-bladder x-ray (KUB). What is included in the preparation?
- A. Keeping the client NPO
- B. Explaining the procedure
- C. Catheterizing the client
- D. Administering an enema
Correct Answer: B
Rationale: Explaining the procedure reduces anxiety and ensures cooperation, a key preparation for a non-invasive KUB x-ray.
The nurse is caring for a client who is postoperative day 1 after a coronary artery bypass graft (CABG). Which of the following findings should the nurse report immediately?
- A. Heart rate of 90 bpm.
- B. Temperature of 100.8°F (38.2°C).
- C. Chest tube drainage of 50 mL/hour.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-CABG complication. Options A, C, and D are normal or expected.
When a client is having a general tonic clonic seizure, the nurse should
- A. Hold the client's arms at their side
- B. Place the client on their side
- C. Insert a padded tongue blade in client's mouth
- D. Elevate the head of the bed
Correct Answer: B
Rationale: Place the client on their side. This position maintains a patent airway and prevents aspiration.
The nurse is teaching a client with a new diagnosis of glaucoma about latanoprost (Xalatan). Which of the following statements by the client indicates a need for further teaching?
- A. I should use this medication at bedtime.
- B. I should report eye pain to my doctor.
- C. I should avoid rubbing my eyes after using it.
- D. I should stop this medication if my vision improves.
Correct Answer: D
Rationale: Stopping latanoprost when vision improves is incorrect, as glaucoma requires lifelong treatment to prevent optic nerve damage. Options A, B, and C are correct: bedtime dosing is standard, eye pain may indicate complications, and avoiding rubbing prevents irritation.
The nurse has a pre-op order to insert a Foley catheter in a male client. The catheter should be inserted:
- A. 1-2 inches
- B. 3-4 inches
- C. 5-6 inches
- D. 7-9 inches
Correct Answer: D
Rationale: In males, a Foley catheter is inserted 7-9 inches to reach the bladder, ensuring proper placement without trauma.