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A 4-year-old admitted with Wilms tumor is scheduled for a right nephrectomy in the morning. Which nursing action is a priority pre-operatively?
- A. Assessment of the child's emotional maturity level
- B. Auscultating for adventitious breath sounds
- C. Monitoring blood pressure closely
- D. Reinforcing instructions not to palpate the abdomen
Correct Answer: D
Rationale: Avoiding abdominal palpation (D) prevents tumor rupture in Wilms tumor, a critical pre-operative priority. Emotional assessment (A), lung sounds (B), and BP monitoring (C) are important but secondary.
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A client with right-sided weakness becomes dizzy, loses balance, and begins to fall while the nurse is assisting with ambulation. Which nursing actions would best prevent injury to the client and nurse while guiding the client to a horizontal position on the floor?
- A. Step behind client with arms around waist, squat using the quadriceps, and lower client to the floor
- B. Step in front of client, brace knees and feet against the client's, and assist to the floor gently
- C. Step slightly behind client with feet apart, extend one leg, and let client slide against it to the floor
- D. Step 12 inches behind the client, support under axillae, tighten back, and lower client to the floor
Correct Answer: C
Rationale: This technique (C) ensures the nurse maintains balance with feet apart and uses their leg to guide the client safely to the floor, minimizing injury risk to both. Option A risks the nurse losing balance, B places the nurse in an unsafe position, and D involves improper body mechanics.
A client with a history of increased intracranial pressure is admitted to the hospital for severe headaches. The client suddenly vomits and states, 'That's weird, I didn't even feel nauseated.' Which action should the nurse take next?
- A. Document the amount of emesis
- B. Lower the head of the bed
- C. Notify the supervising registered nurse
- D. Offer an antinausea medication
Correct Answer: C
Rationale: Sudden vomiting without nausea in increased ICP suggests worsening pressure, requiring immediate RN notification (C). Documentation (A), lowering the bed (B), and antiemetics (D) are secondary.
The family of a 90-year-old resident in a long-term care facility asks the nurse why the client only gets a shower three times a week. What information is most important for the nurse to include when answering the question?
- A. The staff members have limited time and must schedule all the residents.
- B. The client's skin is dry; too many showers will dry the skin further.
- C. The client has limited energy and must conserve it.
- D. The client is not very active and doesn't get very dirty.
Correct Answer: B
Rationale: Frequent showers can exacerbate dry skin in elderly clients, increasing irritation or breakdown risk. Staffing, energy, or activity levels are less relevant to skin health.
The nurse monitoring a client with appendicitis will expect the client to give which description of the associated abdominal pain?
- A. A burning sensation; in the upper abdomen
- B. An 8 out of 10; on the left side below the belly button
- C. Excruciating; in the lower abdomen above the right hip
- D. Intermittent; in the abdomen and right shoulder
Correct Answer: C
Rationale: Appendicitis typically causes severe pain in the right lower quadrant (C). Upper abdominal burning (A) suggests gastritis, left-sided pain (B) is atypical, and shoulder pain (D) may indicate referred pain from other conditions.
A 24-year-old female client is prescribed isotretinoin for severe cystic acne. Which instruction is most important for the nurse to reinforce?
- A. Apply lubricating eye drops when wearing contacts
- B. Do not break, crush, or chew capsules
- C. Use sunscreen routinely during therapy
- D. Use two forms of contraception consistently
Correct Answer: D
Rationale: Isotretinoin is highly teratogenic, so using two forms of contraception (D) is critical to prevent pregnancy. Sunscreen (C) is important for photosensitivity, but contraception is the priority.