an infant born with an imperforate anus returns from surgery after requiring a colostomy the nurse assesses the stoma and notes that it is red and ed
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Nursing Elites

NCLEX-RN

NCLEX RN Practice Questions Exam Cram

1. After surgery for an imperforate anus, an infant returns with a red and edematous colostomy stoma. What action should the nurse take based on this finding?

Correct answer: B

Rationale: A red and edematous colostomy stoma is a common finding immediately after surgery, and these changes are expected to decrease over time. As the stoma heals, it usually becomes pink without signs of abnormal drainage, swelling, or skin breakdown. Therefore, the appropriate action for the nurse is to document these normal findings. Elevating the buttocks, applying ice, or calling the primary health care provider are unnecessary interventions at this stage.

2. A nurse is educating a patient about bimatoprost (Lumigan) eyedrops for the treatment of Glaucoma. Which of the following indicates that the patient has a correct understanding of the expected outcomes following treatment?

Correct answer: B

Rationale: Glaucoma cannot be cured, just treated. Treatment revolves around preventing further deterioration.

3. A man is receiving heparin subcutaneously. The patient has dementia and lives at home with a part-time caretaker. The nurse is most concerned about which side effect of heparin?

Correct answer: C

Rationale: The correct answer is 'Risk for Bleeding.' A patient with dementia may have impaired judgment and may be prone to falls or injuries, increasing the risk of bleeding while on heparin therapy. Monitoring for signs of bleeding is crucial in this situation. Choice A, 'Back Pain,' is not a common side effect of heparin. Choice B, 'Fever and Chills,' is not a typical side effect of heparin but may indicate other underlying conditions. Choice D, 'Dizziness,' is not a common side effect of heparin and is not the primary concern in this scenario.

4. A healthcare professional is reviewing a patient's chart and notices that the patient suffers from conjunctivitis. Which of the following microorganisms is related to this condition?

Correct answer: D

Rationale: The correct answer is Haemophilus aegyptius. Haemophilus influenzae biogroup aegyptius (Hae) is a causative agent of acute and often purulent conjunctivitis, more commonly known as pink eye. Yersinia pestis, Helicobacter pylori, and Vibrio cholerae are not associated with conjunctivitis. Yersinia pestis causes the plague, Helicobacter pylori is associated with gastric ulcers, and Vibrio cholerae causes cholera.

5. Which patient poses the least infection risk to an immunosuppressed patient who had a liver transplant?

Correct answer: C

Rationale: The patient with a healing leg wound poses the least infection risk to an immunosuppressed patient who had a liver transplant. Chronic pancreatitis can lead to complications such as infections that can pose a risk to immunosuppressed individuals. Patients infected with respiratory viruses or urinary tract infections are actively infectious, which can put immunosuppressed patients at a higher risk of acquiring infections. Therefore, the patient with a healing leg wound is the least likely to pose an immediate infection risk.

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