Nokea
A 2-year-old male child has an asymptomatic right flank mass discovered incidentally by the mother while bathing. Suspicion of Wilms tumor is raised. Of the following, the LEAST likely investigation to be performed in this child is
- A. plain abdominal radiography
- B. computerized tomography (CT) scan of the abdomen
- C. CT scan of the chest
- D. biopsy of the mass
Correct Answer: D
Rationale: Biopsy is generally avoided in suspected Wilms tumor to prevent upstaging the disease.
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An adolescent girl calls the nurse at the clinic because she had unprotected sex the night before and does not want to be pregnant. What should the nurse explain to the girl?
- A. It is too late to prevent an unwanted pregnancy
- B. An abortion may be the best option if she is pregnant
- C. Norplant can be administered to prevent pregnancy for up to 5 years
- D. Postcoital contraception is available to prevent implantation
Correct Answer: D
Rationale: In this scenario, the most appropriate option for the nurse to explain to the adolescent girl is postcoital contraception, also known as emergency contraception or the morning-after pill. Postcoital contraception is a method used to prevent pregnancy after unprotected sex or contraceptive failure. It works by preventing or delaying ovulation, inhibiting fertilization, or preventing implantation of a fertilized egg in the uterus.
Which is the most appropriate nursing intervention for the newborn who is jittery and twitching and has a high-pitched cry?
- A. Monitor blood pressure closely.
- B. Obtain urine sample to detect glycosuria.
- C. Obtain serum glucose and serum calcium levels.
- D. Administer oral glucose or, if newborn refuses to suck, IV dextrose.
Correct Answer: C
Rationale: The most appropriate nursing intervention for the jittery and twitching newborn with a high-pitched cry is to obtain serum glucose and serum calcium levels (Option C). These symptoms are indicative of possible hypoglycemia or hypocalcemia, which are common issues for newborns. Monitoring glucose and calcium levels will help identify and address any imbalances that may be causing these symptoms. Administering glucose (Option D) may be necessary if hypoglycemia is confirmed, but it should be based on the results of blood tests. Monitoring blood pressure (Option A) and obtaining a urine sample to detect glycosuria (Option B) are not the priority interventions in this scenario compared to assessing serum glucose and calcium levels.
Wilma knew that James have an adequate respiratory condition if she notices that
- A. James' respiratory rate is 18
- B. James' Oxygen saturation is 91%
- C. There are frank blood suction from the tube
- D. There are moderate amount of tracheobronchial secretions
Correct Answer: A
Rationale: An adequate respiratory condition can be indicated by a normal respiratory rate. The normal adult respiratory rate typically ranges from 12 to 20 breaths per minute. In this case, if James' respiratory rate is 18, it falls within the normal range and would suggest that his respiratory condition is adequate. Oxygen saturation levels and the presence of blood suction or secretions are important factors to consider as well, but directly assessing the respiratory rate provides a more immediate indication of respiratory status.
A client with diabetes mellitus must learn how to self-administer insulin. The physician has prescribed 10 U of U- 100 regular insulin and 35 U of 100-U isophane insulin suspension (NPH) to be taken before breakfast. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction?
- A. "Inject insulin into healthy tissue with large blood vessels and nerves."
- B. "Rotate injection sites within the same anatomic region, not among different regions."
- C. "Administer insulin into areas of scar tissue or hypotrophy whenever possible."
- D. "Administer insulin into sites above muscles that you plan to exercise heavily later that day."
Correct Answer: B
Rationale: The nurse should instruct the client to rotate injection sites within the same anatomic region, not among different regions. Proper rotation of injection sites helps prevent lipodystrophy (changes in fat tissue) and ensures consistent absorption of insulin. By rotating sites within the same region, the client can minimize the risk of developing localized skin complications. Additionally, rotating sites helps to ensure that the insulin is absorbed consistently, leading to more predictable blood glucose control. It is important to avoid injecting into areas of scar tissue, hypotrophy, large blood vessels, or nerves, as these can affect the absorption of insulin and may lead to inconsistent blood glucose levels.
The nurse knows that a client understands a low residue diet when he selects which of the following from the menu?
- A. Rice and lean chicken
- B. Pasta with vegetables
- C. Strawberry pie
- D. Tuna casserole
Correct Answer: A
Rationale: A low residue diet is designed to minimize the amount of undigested food in the stool, therefore reducing the frequency and volume of bowel movements. Foods high in fiber, such as pasta with vegetables and strawberry pie, may not be suitable for a low residue diet as they can increase stool bulk. Tuna casserole may contain ingredients like bread crumbs or high-fiber vegetables that are also not recommended on a low residue diet. Rice and lean chicken are good choices for this diet as they are low in fiber and easy to digest, making them suitable options for a client following a low residue diet.