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Questions 158

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Question 1 of 5

The nurse is teaching circumcision care to the mother of a newborn. Which statement indicates that the mother needs further teaching?

Correct Answer: C

Rationale: Using a heat lamp is incorrect and could cause burns or delay healing. Petroleum gauze, cleaning, and monitoring for infection are appropriate circumcision care practices.

Question 2 of 5

A 70-year-old homeless woman is admitted with pneumonia. She is weak, emaciated, and febrile. The physician orders enteral feedings intermittently by nasogastric tube. When inserting the nasogastric tube, once the tube passes through the oropharynx, the nurse will instruct the client to:

Correct Answer: B

Rationale: Swallowing assists with insertion of tube and closes off airway.

Question 3 of 5

The nurse is developing a plan of care for a client with a newly created ileostomy. The priority nursing diagnosis for this client is:

Correct Answer: A

Rationale: Excessive fluid loss from a new ileostomy can lead to dehydration, making risk for deficient fluid volume the priority nursing diagnosis to ensure physiological stability.

Question 4 of 5

The client is admitted with a diagnosis of acute glomerulonephritis. Which assessment finding is most expected?

Correct Answer: A

Rationale: Hematuria is a hallmark of acute glomerulonephritis due to glomerular inflammation and damage, leading to blood in the urine. Hypertension, weight gain, and oliguria are more common than hypotension, weight loss, or clear urine.

Question 5 of 5

The nurse is assisting a 4th-day postoperative cholecystectomy client in planning her meals for tomorrow's menu. Which vitamin is the most essential in promoting tissue healing?

Correct Answer: A

Rationale: Vitamin C (ascorbic acid) is essential in promoting wound healing and collagen formation. Vitamin B1 (thiamine) maintains normal gastrointestinal (GI) functioning, oxidizes carbohydrates, and is essential for normal functioning of nervous tissue. Vitamin D regulates absorption of calcium and phosphorus from the GI tract and helps prevent rickets. Vitamin A is necessary for the formation and maintenance of skin and mucous membranes. It is also essential for normal growth and development of bones and teeth.

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