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Questions 158

NCLEX-RN

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Question 1 of 5

A two-year-old is hospitalized with suspected intussusception. Which finding is associated with intussusception?

Correct Answer: A

Rationale: Currant jelly stools (bloody, mucousy) are classic in intussusception due to intestinal ischemia. Vomiting and a palpable abdominal mass may occur, but stools and flank masses are less specific.

Question 2 of 5

A two-year-old is hospitalized with suspected intussusception. Which finding is associated with intussusception?

Correct Answer: A

Rationale: Currant jelly stools (bloody, mucousy) are classic in intussusception due to intestinal ischemia. Vomiting and a palpable abdominal mass may occur, but stools and flank masses are less specific.

Question 3 of 5

The physician has ordered a low-sodium diet for a client with hypertension. Which food should the nurse instruct the client to avoid?

Correct Answer: C

Rationale: Canned soups are high in sodium, which exacerbates hypertension. Fresh fruit, grilled chicken, and brown rice are low-sodium options suitable for a hypertension diet.

Question 4 of 5

A physician tells the nurse that he wants to orally intubate a client with a No. 8 endotracheal tube. The finding of normal breath sounds on the right side of the chest and diminished, distant breath sounds on the left side of the chest of a newly intubated client is probably due to:

Correct Answer: C

Rationale: The right mainstem bronchus is most frequently intubated in error because the angle of the right mainstem bronchus is very small as compared with that of the left mainstem bronchus. Because ventilation is only occurring on the right side, the nurse would auscultate diminished and distant breath sounds on the left.

Question 5 of 5

The nurse is caring for a client with a history of a pleural effusion who is scheduled for a thoracentesis. The nurse should:

Correct Answer: C

Rationale: Sitting upright with arms supported facilitates access to the pleural space during thoracentesis and reduces complications. Sedatives and fluid restrictions are not routine.

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