ATI Detailed Answer Key peds Nclex Questions and answers

1. A nurse is providing teaching to a parent of a child who has Hirschsprung disease is scheduled for initial surgery. Which of the following statements by the parent indicates an understanding of the teaching? A. "I'm glad that my child's ostomy is only temporary." Rationale: Hirschsprung disease is also known as aganglionic megacolon and is characterized by an area of the large intestine without nerve innervation. The child will probably require two surgeries over an 18- to 24-month period before normal bowel function is obtained. The initial surgery creates an ostomy, which relieves the obstructed area and allows the bowel distal to the ostomy to rest. B. "I'm glad my child will have normal bowel movements now." Rationale: The child will not have bowel movements after the initial surgery. C. "I want to learn how to use my child's feeding tube as soon as possible." Rationale: The child will not have a feeding tube after the surgery. D. "I want to learn how to empty my child's urinary catheter bag." Rationale: The child will not have a urinary catheter after the surgery. 2. A parent calls a clinic and reports to a nurse that his 2-month-old infant is hungry more than usual but is projectile vomiting immediately after eating. Which of the following responses should the nurse make? A. "Bring your baby in to the clinic today." Rationale: Projectile vomiting followed by hunger are characteristic of pyloric stenosis. The infant needs to be examined in the clinic by a provider as soon as possible. B. "Burp your baby more frequently during feedings." Rationale: Burping the infant does not address the cause of the projectile vomiting. C. "Give your infant an oral rehydration solution." Rationale: Administering an oral rehydration solution does not address the cause of the projectile vomiting. D. "Try switching to a different formula." Rationale: Switching to a different formula does not address the cause of the projectile vomiting. 3. A nurse is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client? A. Identify the client's nutritional status. Rationale: According to the nursing process, the nurse should perform an assessment first to gather enough data regarding nutritional status and other findings in order to plan, implement, and evaluate care. The assessment identifies client nutrition needs as well as complications the client might be experiencing related to the eating disorder. B. Request a mental health consult. Rationale: Requesting a mental health consult might be necessary but another aspect of care is the priority. C. Plan a therapeutic diet for the client. Rationale: Rationale C. Planning a therapeutic diet for the client will be necessary but another aspect of care is the priority. D. Provide a structured environment for the client. Rationale: It is important to provide a structured environment for the client regarding meals, times for weighing, and monitoring of eating, but another aspect of care is the priority. 4. A nurse is teaching a client who has gastroesophageal reflux disease about managing his illness. Which of the following recommendations should the nurse include in the teaching? A. Limit fluid intake not related to meals. Rationale: The nurse should recommend consuming liquids between meals rather than with meals to help reduce abdominal distention. B. Chew on mint leaves to relieve indigestion. Rationale: The nurse should instruct the client to avoid items like mint that can increase gastric acid secretion. C. Avoid eating within 3 hr of bedtime. Rationale: The nurse should instruct the client to eat small, frequent meals but to avoid eating with 3 hr of bedtime. D. Season foods with black pepper. Rationale: The nurse should instruct the client to avoid items such as black and red pepper that can increase gastric acid secretion. 5. A nurse is providing teaching for a client who has anemia and a new prescription for ferrous sulfate liquid. Which of the following instructions should the nurse provide? A. Take the medication on an empty stomach to decrease gastrointestinal irritation. Rationale: Taking iron on an empty stomach may increase gastrointestinal side effects. B. Take the medication with orange juice to enhance absorption. Rationale: Ascorbic acid (vitamin C), which is found in orange juice, will enhance the absorption of iron and increase its bioavailability. This will also help to decrease the gastrointestinal side effects of iron. C. Take the medication with milk. Rationale: Iron should not be taken with milk or antacids, because it decreases the absorption. D. Rinse the mouth before taking the iron. Rationale: The client should rinse the mouth after taking the ferrous sulfate liquid to prevent the medication from staining the teeth.