What is the cardinal sign a nurse would expect to observe with intussusception?
Red, currant, jelly-like stools
Absent bowel sounds
Hematemesis
Bilious emesis
The Correct Answer is A
a) Red, currant, jelly-like stools: This is a classic indication of intussusception due to the presence of blood and mucus in the stool, a result of intestinal obstruction and ischemia.
b) Absent bowel sounds: Can occur but are not specific to intussusception.
c) Hematemesis: Vomiting blood is not a characteristic sign of intussusception.
d) Bilious emesis: While indicative of gastrointestinal issues, it's not the cardinal sign of intussusception.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a) Risk for aspiration related to regurgitation: With esophageal atresia and tracheoesophageal fistula, the risk of aspiration due to the abnormal connection between the trachea and esophagus is a significant concern. Preventing aspiration is a priority.
b) Acute pain related to esophageal defect: Pain might be present but managing the risk of aspiration is more immediate.
c) Ineffective tissue perfusion gastrointestinal related to decreased circulation: While important, preventing aspiration takes precedence.
d) Ineffective feeding pattern related to uncoordinated suck and swallow: A valid concern but not as critical as the risk of aspiration.
Correct Answer is D
Explanation
a) Carrots and green leafy vegetables: These are generally low in potassium and would be considered safer options for someone with hyperkalemia.
b) Spaghetti and meat sauce, breadsticks: These typically don't contain high potassium levels compared to other choices.
c) Hamburger on a bun, cherry gelatin: Unlikely to be high in potassium.
d) Chips, cold cuts, and canned foods: These can be high in added salts and preservatives, leading to higher potassium content. Therefore, they should be avoided by individuals managing hyperkalemia due to renal failure.
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