NR 328 Week 5 Exam 2; 100 NCLEX Revision

The nurse is providing discharge instructions to parents of a 3-year-old recovering from acute gastroenteritis. Which statement by the parents indicates a need for further teaching? A. "We'll continue to give small amounts of fluids frequently." B. "We'll avoid dairy products for the next 2-3 weeks." C. "We'll monitor for signs of dehydration like decreased urination." D. "We'll gradually reintroduce a regular diet as tolerated." Answer: B. "We'll avoid dairy products for the next 2-3 weeks." Rationale: Avoiding dairy products for 2-3 weeks is unnecessarily restrictive. While temporary lactose intolerance can develop following gastroenteritis, most children can resume their normal diet, including dairy, within 24-48 hours as tolerated. Gradual reintroduction of regular diet, continued oral rehydration, and monitoring for dehydration are appropriate discharge instructions. Question 4 A 1-year-old child with acute gastroenteritis has been receiving IV fluids for severe dehydration. The nurse recognizes that the child is ready for oral rehydration when: A. The child is afebrile for 24 hours B. Vomiting has completely stopped C. Diarrhea has completely resolved D. Oral mucosa is moist and urine output is adequate Answer: D. Oral mucosa is moist and urine output is adequate Rationale: Adequate hydration status, as evidenced by moist mucous membranes and appropriate urine output, indicates that the child is ready to transition from IV to oral rehydration. Fever, vomiting, and diarrhea may still be present but improving as the child recovers. The goal is to transition to oral intake as soon as dehydration is corrected, even if other symptoms persist. Question 5 The nurse is caring for a 4-year-old with a diagnosis of intussusception. Which assessment finding would the nurse expect in this child? A. Projectile vomiting after feeding B. Clay-colored stools C. Current-jelly stools D. Tarry stools Answer: C. Current-jelly stools A 2-month-old infant diagnosed with pyloric stenosis is scheduled for a pyloromyotomy. The nurse should expect which clinical manifestation in this infant? A. Diarrhea with mucus B. Projectile vomiting C. Blood-streaked stool D. Progressive abdominal distention Answer: B. Projectile vomiting Rationale: Projectile (forceful) non-bilious vomiting is the classic presentation of pyloric stenosis due to the hypertrophy and narrowing of the pyloric sphincter, which obstructs gastric emptying. Diarrhea with mucus may indicate an infectious process, blood-streaked stool suggests intestinal inflammation or intussusception, and progressive abdominal distention is more consistent with intestinal obstruction. Question 9 A nurse is caring for an infant with gastroesophageal reflux disease (GERD). Which nursing interventions would be appropriate? (Select all that apply) A. Positioning the infant flat after feeding B. Elevating the head of the crib 30 degrees C. Thickening formula with rice cereal as prescribed D. Administering feedings continuously via feeding pump E. Burping the infant frequently during and after feeding Answer: B, C, E Rationale: For an infant with GERD, appropriate interventions include elevating the head of the crib (B) to reduce reflux by gravity, thickening feeds with rice cereal as prescribed (C) to increase the weight of stomach contents, and frequent burping (E) to release swallowed air. The infant should not