A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus, and tells the nurse the quarter is supposed to fix her child's hernia. Which explanation should the nurse provide?
An abdominal binder can be worn daily to reduce the protrusion.
This hernia is a normal variation that resolves without treatment.
The quarter should be secured with an elastic bandage wrap.
Restrictive clothing will be adequate to help the hernia go away.
The Correct Answer is B
Choice A reason: An abdominal binder can be worn daily to reduce the protrusion is not a correct explanation for the nurse to provide, as this is not an effective or recommended method to treat a hernia. This is a distractor choice.
Choice B reason: This hernia is a normal variation that resolves without treatment is a correct explanation for the nurse to provide, as this refers to an umbilical hernia, which is a common and harmless condition in infants that usually disappears by age 2. Therefore, this is the correct choice.
Choice C reason: The quarter should be secured with an elastic bandage wrap is not a correct explanation for the nurse to provide, as this is a folk remedy that has no scientific basis and can cause skin irritation and infection. This is another distractor choice.
Choice D reason: Restrictive clothing will be adequate to help the hernia go away is not a correct explanation for the nurse to provide, as this is not a proven or safe way to treat a hernia. This is another distractor choice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1"]
Explanation
To calculate how many mL/hr the nurse should program the infusion pump, we need to use the following formula:
mL/hr = (units/hr) / (units/mL)
where units/hr is the prescribed dose of insulin per hour, and units/mL is the concentration of insulin in the IV solution.
In this case, we are given that:
units/hr = 1 unit (the usual starting dose for IV insulin)
units/mL = 100 units / 100 mL = 1 unit/mL
Plugging these values into the formula, we get:
mL/hr = (1 unit/hr) / (1 unit/mL)
mL/hr = 1 mL/hr
Therefore, the nurse should program the infusion pump to deliver 1 mL/hr.
Correct Answer is C
Explanation
Choice A reason: Securing chest tube to the stretcher for transport is not the most important action for the nurse to take. Chest tube is a device that drains air or fluid from the pleural space or mediastinum after surgery or trauma. Securing chest tube to the stretcher can prevent accidental dislodgement or kinking of the tube during transport, but it is not as crucial as maintaining proper drainage.
Choice B reason: Marking the amount of chest drainage on the container is not the most important action for the nurse to take. Chest drainage is the fluid or air that collects in the chest tube container after being drained from the pleural space or mediastinum. Marking the amount of chest drainage on the container can help monitor fluid balance and detect excessive bleeding or leakage, but it is not as vital as ensuring proper drainage.
Choice C reason: This is the correct answer because keeping chest tube container below the site of insertion is the most important action for the nurse to take. Chest tube container is a device that collects air or fluid from the chest tube and maintains negative pressure in the pleural space or mediastinum. Keeping chest tube container below the site of insertion can prevent backflow of air or fluid into the chest cavity and maintain adequate drainage. If the chest tube container is raised above the site of insertion, it can cause tension pneumothorax, which is a life-threatening condition that occurs when air accumulates in the pleural space and compresses the lung and heart.
Choice D reason: Administering PRN pain medication prior to transport is not a timely action for the nurse to take. Pain medication is a drug that relieves pain by blocking pain signals or reducing inflammation. Administering pain medication prior to transport can improve comfort and reduce anxiety for the client, but it is not as urgent as preventing complications.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today