A nurse is assisting with the care of a child who has suspected intussusception. Which of the following manifestations is an expected finding?

Projectile vomiting

Periorbital edema

Stools that contain currant jelly-like mucus

Visible gastric peristaltic waves

Answer and Explanation

The Correct Answer is C

Rationale:

A. Projectile vomiting: Projectile vomiting is more commonly associated with pyloric stenosis in infants, not intussusception. While vomiting may occur in intussusception, it is typically bilious and not forceful or projectile in nature.

B. Periorbital edema: Periorbital edema is typically related to renal or allergic conditions such as nephrotic syndrome or severe allergic reactions. It is not associated with gastrointestinal issues like intussusception.

C. Stools that contain currant jelly-like mucus: Intussusception causes bowel telescoping, leading to obstruction and compromised blood flow. This results in stools containing blood and mucus, often described as “currant jelly,” which is a hallmark symptom of the condition.

D. Visible gastric peristaltic waves: Visible peristalsis is more indicative of pyloric stenosis, where there is hypertrophy of the pyloric muscle. It is not typically seen in cases of intussusception.

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Correct Answer is B

Explanation

Rationale:

A. Encourage the client to increase fluid intake: Clients undergoing peritoneal dialysis often have fluid restrictions based on residual renal function and ultrafiltration goals. Increasing fluid intake without specific provider guidance may lead to fluid overload.

B. Obtain the client's weight: Daily weight measurement is essential in peritoneal dialysis to assess fluid removal effectiveness and detect signs of fluid retention or dehydration. Weight changes help guide dialysis fluid volume and concentration adjustments.

C. Palpate the access site for a thrill: A thrill is assessed in clients with an arteriovenous (AV) fistula or graft used for hemodialysis, not peritoneal dialysis. Peritoneal dialysis uses a catheter placed in the abdominal cavity, which does not produce a thrill.

D. Auscultate the access site for a bruit: A bruit is associated with blood flow through an AV fistula or graft used in hemodialysis. In peritoneal dialysis, the access is a soft catheter, and auscultation for a bruit is not applicable or expected.

A. Mix the medication in juice prior to administration B. Administer the medication when the toddler has an acute asthma attack C. Provide an additional dose of the medication prior to physical activity. D. Administer the medication to the toddler each evening

Correct Answer is D

Explanation

Rationale:

A. Mix the medication in juice prior to administration: Montelukast can be mixed with soft foods like applesauce, but mixing it in juice is not specifically recommended due to potential taste masking and dosing accuracy issues. Instructions should follow the manufacturer’s guidelines.

B. Administer the medication when the toddler has an acute asthma attack: Montelukast is a maintenance medication used to prevent asthma symptoms and is not effective for treating acute asthma attacks. A rescue inhaler like albuterol should be used during acute episodes.

C. Provide an additional dose of the medication prior to physical activity: Montelukast is not typically dosed in response to physical activity. While it can help prevent exercise-induced bronchospasm, it should be taken once daily in the evening, not additionally before exertion.

D. Administer the medication to the toddler each evening: Montelukast is prescribed as a once-daily maintenance therapy and is most effective when given in the evening. This helps maintain consistent blood levels and prevents nighttime asthma symptoms.

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A nurse is assisting with the care of a child who has suspected intussusception. Which of the following manifestations is an expected finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the plan of care for a client who is scheduled for continuous peritoneal dialysis. Which of the following actions should the nurse recommend?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with the parents of a toddler who has a new diagnosis of asthma and a prescription for montelukast. Which of the following instructions should the nurse include in the teaching?

Correct Answer is D

Explanation

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