Nursing Elites

1. A 6-month-old infant with Hirschsprung disease is scheduled for a temporary colostomy. What should postoperative teaching to the parents include?

• A. Dilating the stoma
• B. Assessing bowel function
• C. Limitation of physical activities
• D. Measures to prevent prolapse of the rectum

Correct answer: B

Rationale: Postoperative teaching should focus on assessing bowel function to ensure the colostomy is functioning properly. This includes monitoring stool output, color, consistency, and signs of infection or blockage. Choice A, dilating the stoma, is not recommended without healthcare provider guidance, as it can lead to complications. Choice C, limitation of physical activities, may not be as crucial immediately after colostomy creation. Choice D, measures to prevent prolapse of the rectum, is more relevant for conditions like rectal prolapse and not specifically for a colostomy.

2. The nurse is seeing an adolescent and the parents in the clinic for the first time. Which should the nurse do first?

• A. Introduce him- or herself
• B. Make the family comfortable
• C. Give assurance of privacy
• D. Explain the purpose of the interview

Correct answer: A

Rationale: Introducing oneself is the first step in establishing a rapport and setting a professional tone for the interaction.

3. The nurse is caring for a child with a urinary tract infection who is on trimethoprim-sulfamethoxazole (Bactrim). What side effects of this medication should the nurse teach to the parents and the child? (Select all that apply.)

• A. Rash
• B. Urticaria
• C. All are applicable
• D. Photosensitivity

Correct answer: C

Rationale: Trimethoprim-sulfamethoxazole (Bactrim) can cause side effects like rash, urticaria, and photosensitivity. Parents and the child should be educated on these potential side effects to ensure prompt recognition and management.

4. When checking the intravenous (IV) site on a child, the nurse should take which action?

• A. Look at the site.
• B. Ask the child if the site hurts.
• C. Look at the site while palpating the area.
• D. Take all the tape off, assess the site, and redress.

Correct answer: C

Rationale: Looking at and palpating the IV site helps assess for signs of infiltration or infection, such as swelling, redness, or pain. Simply looking or asking the child may miss subtle signs, and removing all the tape unnecessarily disrupts the site.

5. What pathologic process is believed to be responsible for the development of postinfectious glomerulonephritis?

• A. Infarction of renal vessels
• B. Immune complex formation and glomerular deposition
• C. Bacterial endotoxin deposition on and destruction of glomeruli
• D. Embolization of glomeruli by bacteria and fibrin from endocardial vegetation

Correct answer: B

Rationale: Postinfectious glomerulonephritis is typically caused by immune complex deposition in the glomeruli following a streptococcal infection. This immune response leads to inflammation and impaired kidney function.

Similar Questions