Questions 150

NCLEX-RN

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Question 1 of 5

A child with the diagnosis of Hirschsprung's disease has a temporary colostomy. The nurse provides instructions to the parents about colostomy care at home. Which statement by the parents indicates their understanding of the instructions?

Correct Answer: B

Rationale: The parents are instructed to report signs of skin breakdown or stomal complications, such as ribbonlike stools or failure to pass flatus or stools, to the primary health care provider or the nurse. Moist, red granulation tissue may grow around an ostomy site and does not require special treatment. The remaining options are incorrect actions and considered contraindicated.

Question 2 of 5

A client with a history of peptic ulcer disease is admitted to the hospital. Initial assessment reveals that his blood pressure is 96/60 mm Hg, his pulse rate is 120 bpm, and he has vomited coffee-ground material. Based on this assessment, what is the nurse's priority action?

Correct Answer: D

Rationale: The symptoms suggest gastrointestinal bleeding, and the modified Trendelenburg position helps maintain cerebral perfusion in hypovolemic shock.

Question 3 of 5

The nurse is caring for a client with a venous leg ulcer. Which of the following interventions should be included in the plan of care?

Correct Answer: A

Rationale: Compression bandages promote venous return and healing in venous leg ulcers.

Question 4 of 5

A 15-month-old child is admitted to the pediatric unit with the diagnosis of pneumonia and is placed in a mass test. Which following toys would be appropriate for this child?

Correct Answer: D

Rationale: Plastic blocks are safe and age-appropriate for a 15-month-old, promoting fine motor skills without posing a choking hazard or requiring mobility restricted by a mist tent.

Question 5 of 5

A client who had a transurethral resection of the prostate (TURP) 1 day earlier has a three-way Foley catheter inserted for continuous bladder irrigation. Which of the following statements best explains why continuous irrigation is used after TURP?

Correct Answer: C

Rationale: Continuous irrigation prevents clot formation and obstruction in the catheter, ensuring proper drainage post-TURP.

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