A nurse in an acute care facility is caring for a toddler.

For each assessment finding below, click to specify if the assessment finding is consistent with Crohn’s disease, appendicitis, or intussusception. Each finding may support more than 1 disease process.

Pain rating

Vomiting

Temperature

Stool

Abdominal findings

Answer and Explanation

The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B,C"},"C":{"answers":"B"},"D":{"answers":"A,C"},"E":{"answers":"C"}}

• Pain rating: The child’s history describes sudden, severe abdominal pain causing the child to draw their knees to their chest, with periods of relief between episodes. This episodic, colicky pain is classic for intussusception, as the bowel telescopes and intermittently obstructs intestinal flow.

• Vomiting: The child vomited approximately 50 mL of light-colored emesis, consistent with the obstruction caused by intussusception. Vomiting can also occur in appendicitis due to peritoneal irritation, particularly if inflammation is in the right upper quadrant.

• Temperature: The child has a mild fever of 37.4° C (99.3° F). This low-grade fever can indicate inflammation of the appendix, making appendicitis a consideration. Intussusception usually does not present with fever unless there is ischemia or infection, which is not indicated.

• Stool: The parent reports blood and mucus in the stool, which is classic “currant jelly” stool seen in intussusception. Crohn’s disease may also present with blood and mucus due to chronic bowel inflammation, but the sudden onset and combination with severe colicky pain point more strongly toward intussusception.

• Abdominal findings: On assessment, the child’s abdomen is distended with hypoactive bowel sounds and tenderness in the right upper quadrant, and a small, oblong palpable mass is noted in the same area. These findings are highly specific for intussusception, representing the telescoped segment of bowel that can be palpated as a sausage-shaped mass.

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Correct Answer is A

Explanation

A. Prime the tubing with 0.9% sodium chloride: Blood products must be administered with 0.9% sodium chloride to prevent hemolysis. Priming the tubing with saline ensures compatibility and maintains patency, allowing safe and effective transfusion without compromising the integrity of red blood cells.

B. Attach a single-line administration set: Blood transfusions require a specialized Y-type or filtered tubing to reduce the risk of clots, debris, and air embolism. Using a single-line set without a filter could allow microaggregates to enter the circulation.

C. Use tubing that does not have a filter in the drip chamber: A filter is essential for removing clots, debris, and cellular aggregates from the blood product. Administering blood without a filter increases the risk of complications such as emboli and febrile reactions.

D. Use an IV catheter that is at least 24-gauge: A 24-gauge catheter is too small for safe transfusion of blood products. A larger-bore catheter, typically 18–20 gauge, is recommended to allow adequate flow and prevent hemolysis or catheter rupture during transfusion.

A. Offer the client saltine crackers between meals. B. Instruct the client on the use of esophageal speech. C. Provide humidification of the room air. D. suggest rinsing his mouth with an alcohol-based mouth wash.

Correct Answer is C

Explanation

A. Offer the client saltine crackers between meals: Dry foods like saltine crackers can worsen the discomfort associated with xerostomia and may irritate oral mucosa. They are not recommended for managing dry mouth.

B. Instruct the client on the use of esophageal speech: Esophageal speech is a technique used after laryngectomy, not for managing xerostomia. It does not address the underlying issue of dry mouth caused by radiation therapy.

C. Provide humidification of the room air: Humidifying the room adds moisture to the environment, helping relieve dryness in the oral cavity and throat. This intervention is appropriate for managing xerostomia and improving comfort for clients post-radiation therapy.

D. Suggest rinsing his mouth with an alcohol-based mouthwash: Alcohol-based mouthwashes can further dry and irritate the oral mucosa, worsening xerostomia. Clients should be advised to use non-alcoholic, moisturizing rinses instead.

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A nurse in an acute care facility is caring for a toddler. For each assessment finding below, click to specify if the assessment finding is consistent with Crohn’s disease, appendicitis, or intussusception. Each finding may support more than 1 disease process.

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a blood transfusion to a client. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse?

Correct Answer is C

Explanation

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A nurse in an acute care facility is caring for a toddler.

For each assessment finding below, click to specify if the assessment finding is consistent with Crohn’s disease, appendicitis, or intussusception. Each finding may support more than 1 disease process.