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A 6-month-old child is discharged with a urinary stent after a procedure to repair a hypospadias. The nurse should tell the parents to:
- A. Avoid tub baths until the stent is removed.
- B. Measure output in the urinary bag.
- C. Avoid drinking fruit juice.
- D. Clean the tip of the penis 3 times a day with soap and water.
Correct Answer: A
Rationale: Avoiding tub baths prevents infection.
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A school-age client admitted to the hospital because of decreased urine output and periorbital edema is diagnosed with acute poststreptococcal glomerulonephritis. Which of the following actions should receive the highest priority?
- A. Assessing vital signs every 4 hours.
- B. Monitoring intake and output every 12 hours.
- C. Obtaining daily weight measurements.
- D. Obtaining serum electrolyte levels daily.
Correct Answer: C
Rationale: Weight reflects fluid status.
When obtaining the initial health history from a 10-year-old child with abdominal pain and suspected appendicitis, which of the following questions would be most helpful in eliciting data to help support the diagnosis?
- A. Where did the pain start?
- B. What did you do for the pain?
- C. How often do you have a bowel movement?
- D. Is the pain continuous, or does it let up?
Correct Answer: A
Rationale: Pain starting near the umbilicus and migrating to the right lower quadrant is characteristic of appendicitis.
Which sign should lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation?
- A. Hemorrhagic skin rash.
- B. Edema.
- C. Cyanosis.
- D. Dyspnea on exertion.
Correct Answer: A
Rationale: A hemorrhagic rash, such as petechiae or purpura, is a hallmark of disseminated intravascular coagulation in meningitis, indicating clotting abnormalities.
An infant is to be discharged after surgery for intussusception. In developing the discharge teaching plan, the nurse should tell the mother?
- A. The infant will experience a change in the normal home routine.
- B. The infant can return to the prehospital routine immediately.
- C. The infant needs to ingest more calories at home than normal.
- D. The infant will continue to experience abdominal cramping for a few days.
Correct Answer: B
Rationale: After successful surgery, the infant can typically resume normal routines unless complications arise.
A child is admitted to the pediatric unit with the diagnosis of severe gastroenteritis. To prevent spread of the disease the nurse should?
- A. Institute standard precautions.
- B. Place the child in a semiprivate room.
- C. Serve meals with eating utensils that can be sterilized.
- D. Single-bag all linens.
Correct Answer: A
Rationale: Standard precautions prevent the spread of infectious gastroenteritis.