the nurse is preparing to care for a child with a diagnosis of intussusception the nurse reviews the childs record and expects to note which sign of t the nurse is preparing to care for a child with a diagnosis of intussusception the nurse reviews the childs record and expects to note which sign of t
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NCLEX RN Practice Questions Exam Cram

1. The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented?

Correct answer: D: Bright red blood and mucus in the stools

Rationale: Intussusception is a condition where a part of the bowel slides into the next section, causing an obstruction. The classic presentation includes severe abdominal pain that is crampy, intermittent, and may cause the child to draw knees to the chest. While vomiting can occur, it is not typically projectile in nature. A key hallmark of intussusception is the passage of bright red blood and mucus in the stools, often described as currant jelly-like. Watery diarrhea and ribbon-like stools are not typical signs of intussusception and should not be expected in a child with this condition.

2. A male client is laughing at a television program with his wife when the evening nurse enters the room. He says his foot is hurting and he would like a pain pill. How should the nurse respond?

Correct answer: Ask him to rate his pain on a scale of 1 to 10.

Rationale: Obtaining a subjective estimate of the pain experience by asking the client to rate his pain helps the nurse determine which pain medication should be administered and also provides a baseline for evaluating the effectiveness of the medication. Medicating for pain should not be delayed to use it as a sleep medication, so encouraging him to wait until bedtime is incorrect. Option C is judgmental and inappropriate as all clients deserve prompt attention. Option D should be used as an adjunct to pain medication, not instead of medication, so instructing him in deep breathing exercises alone is not the priority in this situation.

3. Which of the following outcomes is most appropriate during the crisis stage of caring for a victim of domestic violence?

Correct answer: The client will be safe and receive treatment for injuries.

Rationale: During the crisis stage of caring for a victim of domestic violence, the immediate priority is ensuring the client's safety and providing treatment for any injuries sustained. This focuses on addressing the urgent physical and emotional needs of the victim. While options like verbalizing community resources or creating safety plans are important for long-term support, they are not the primary concerns during the crisis phase. Contacting an attorney for legal assistance, though vital in the future, is not the immediate priority during the crisis stage when the client's safety and health are at the forefront.

4. A child is admitted to the hospital with a diagnosis of Wilms tumor, stage II. Which of the following statements most accurately describes this stage?

Correct answer: The tumor extended beyond the kidney but was completely resected.

Rationale: In Wilms tumor staging, stage II indicates that the tumor extends beyond the kidney but is completely resected. This means that the tumor has spread beyond the kidney but has been successfully removed. Choices A and B are incorrect because a tumor less than 3 cm in size and a tumor that did not extend beyond the kidney do not align with the characteristics of stage II Wilms tumor. Choice D is also incorrect as it describes a more advanced stage where the tumor has spread into the abdominal cavity and cannot be completely resected. Therefore, the correct answer is C, as it accurately reflects the characteristics of a stage II Wilms tumor.

5. What is the proper personal protective equipment necessary for collecting a sputum specimen?

Correct answer: Gloves and face mask

Rationale: When collecting a sputum specimen, it is crucial to protect against potential airborne droplets that may spread disease. The best personal protective equipment for this task includes gloves and a face mask. Gloves help prevent the spread of contaminants through hand contact, while a face mask protects the respiratory tract from inhaling infectious agents. Choice B, Level Three Biocontainment uniforms, is excessive and unnecessary for routine sputum specimen collection. Choice C, eye protection and shoe covers, does not address the specific risks associated with sputum collection. Choice D, splash shield and face mask, provides additional protection that is not typically required for sputum specimen collection, making it less appropriate than gloves and a face mask.

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