the nurse is caring for an infant after repair of an inguinal hernia which of these assessment findings indicates that the surgical repair was effecti
Logo

Nursing Elites

NCLEX-RN

Exam Cram NCLEX RN Practice Questions

1. After repair of an inguinal hernia, the infant is being cared for. Which assessment finding indicates that the surgical repair was effective?

Correct answer: D

Rationale: The absence of inguinal swelling when the infant cries or strains indicates that the surgical repair of the inguinal hernia was effective. Inguinal swelling typically occurs with crying or straining in cases of this condition. A clean, dry incision signifies the absence of wound infection post-surgery but does not directly indicate the effectiveness of the hernia repair. Abdominal distension suggests a gastrointestinal issue unrelated to the hernia repair. An adequate flow of urine is not specific to evaluating the success of inguinal hernia repair.

2. Which finding would necessitate an immediate change in the therapeutic plan for a patient with grade 2 hepatic encephalopathy?

Correct answer: B

Rationale: A positive urine pregnancy test would require an immediate change in the therapeutic plan for a patient with grade 2 hepatic encephalopathy due to the teratogenic effects of ribavirin. Ribavirin needs to be discontinued immediately to prevent harm to the fetus. The other options, weight loss, hemoglobin level, and complaints of nausea and anorexia, are common adverse effects of the prescribed regimen and may necessitate interventions such as patient education or supportive care, but they would not mandate an immediate cessation of therapy as in the case of a positive pregnancy test.

3. The nurse is caring for a 73-year-old man with cirrhosis. Which data obtained by the nurse during the assessment will be of most concern?

Correct answer: B

Rationale: The most concerning data obtained by the nurse is the patient's hands flapping back and forth when the arms are extended, indicating asterixis, which is associated with hepatic encephalopathy. This condition can progress to hepatic coma and requires immediate attention. The presence of spider angiomas and right upper-quadrant abdominal pain are common findings in cirrhosis and do not warrant urgent intervention. Although ascites and weight gain suggest the need for treatment, they are not as alarming as the neurologic manifestations seen in hepatic encephalopathy.

4. The clinic nurse is obtaining data about a child with a diagnosis of lactose intolerance. Which data should the nurse expect to obtain on assessment?

Correct answer: A

Rationale: Lactose intolerance commonly presents with frothy stools and diarrhea due to the inability to digest lactose. Other symptoms include abdominal distension, crampy abdominal pain, and excessive flatus. Foul-smelling ribbon stools are indicative of Hirschsprung's disease, not lactose intolerance. Profuse, watery diarrhea and vomiting are more characteristic of celiac disease. Diffuse abdominal pain unrelated to meals or activity is a typical symptom of irritable bowel syndrome, not lactose intolerance.

5. A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan?

Correct answer: C

Rationale: In acute bronchitis, which is often viral, cough suppressants can help manage the symptoms of a nonproductive cough. Antibiotics are not typically used in acute bronchitis unless there are systemic symptoms indicating a bacterial infection. Limiting oral fluid intake is not recommended; in fact, maintaining adequate hydration is important. Safety concerns with home oxygen therapy may not be directly relevant to the management of acute bronchitis.

Similar Questions

The patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action by the nurse?
A client is being instructed in the use of an incentive spirometer. Which of the following statements from the nurse indicates correct teaching about using this device?
A mother brings her child to the well-child clinic and expresses concern to the nurse because the child has been playing with another child diagnosed with hepatitis. The nurse prepares to perform an assessment on the child, knowing that which finding would be of least concern for hepatitis?
A child is diagnosed with a Greenstick Fracture. Which of the following most accurately describes the broken bone?
A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would:

Access More Features

NCLEX RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses