NCLEX-RN
Exam Cram NCLEX RN Practice Questions Questions
Question 1 of 5
After hydrostatic reduction for intussusception, what client response should the nurse expect to observe?
Correct Answer: D
Rationale: After hydrostatic reduction for intussusception, the nurse should observe the passage of barium or water-soluble contrast with stools. This indicates a successful reduction of the telescoped bowel segment. Abdominal distension and currant jelly-like stools are clinical manifestations of intussusception, not expected outcomes following hydrostatic reduction. Severe, colicky-type pain with vomiting suggests an unresolved gastrointestinal issue, not a successful reduction of intussusception.
Question 2 of 5
Which entry in the medical record best meets the requirement for problem-oriented charting?
Correct Answer: B
Rationale: Problem-oriented documentation uses the first letter of key words to organize data: S for subjective data, O for objective data, A for assessment, P for plan, I for intervention, and E for evaluation. The correct answer demonstrates problem-oriented charting by following this structure. Choice A, C, and D do not follow the problem-oriented charting format and instead offer examples of different documentation styles such as PIE charting, focus documentation, and narrative documentation, respectively. Therefore, choice B is the best example of problem-oriented charting among the options provided.
Question 3 of 5
A child presents to the emergency department with colicky abdominal pain in the lower right quadrant. What disorder is suspected based on these symptoms?
Correct Answer: B
Rationale: The child's presentation of colicky abdominal pain in the lower right quadrant is classic for appendicitis. Appendicitis typically presents with localized pain that starts near the umbilicus and then shifts to the right lower quadrant. Peritonitis, on the other hand, is characterized by diffuse abdominal pain, tenderness, and guarding, usually resulting from organ perforation or intestinal obstruction. Intussusception is associated with acute, severe abdominal pain and currant jelly-like stools due to intestinal telescoping. Hirschsprung's disease, which lacks ganglion cells in the colon, manifests with symptoms like constipation, abdominal distension, and foul-smelling, ribbon-like stools.
Question 4 of 5
The parents of a child with a hernia are instructed by the nurse on measures to reduce the hernia. Which statement indicates the parents understand the care for their child?
Correct Answer: C
Rationale: The correct answer is providing comfort measures to reduce any crying periods by the child. This can include offering a warm bath, avoiding upright positioning, and using other comfort measures to reduce crying, which can help reduce a hernia. Encouraging coughing or physical activity can increase strain on the hernia. Giving a Fleet enema daily for constipation is not recommended as it can also increase strain on the hernia.
Question 5 of 5
An emergency department nurse is performing an assessment on a child with a suspected diagnosis of intussusception. Which assessment question for the parents will elicit the most specific data related to this disorder?
Correct Answer: D
Rationale: The correct answer is asking the parents to describe the type of pain the child is experiencing because a report of severe colicky abdominal pain in a healthy, thriving child between 3 and 17 months of age is the classic presentation of intussusception. Typical behavior includes screaming and drawing the knees up to the chest. This specific question helps in identifying the key symptom of intussusception. Choices A, B, and C are important aspects of a health history but are not specific to the diagnosis of intussusception. Food allergies, bowel movements, and recent food intake are relevant for a comprehensive assessment but do not directly relate to the specific symptoms of intussusception.