Nokea
A mother noticed a large abdominal mass when helping her 3-year-old child bathe. The child is taken to the physician and admitted to the hospital after an intravenous pyelogram (IVP) confirms the diagnosis of Wilms' tumor. Which nursing action is essential to include in the nursing care plan?
- A. Strain all urine and save for analysis.
- B. Avoid palpating the abdomen.
- C. Prepare the child for permanent dialysis.
- D. Help the family understand the poor prognosis.
Correct Answer: B
Rationale: Avoiding abdominal palpation prevents potential tumor rupture or metastasis in Wilms' tumor, a critical precaution. Urine straining, dialysis, or poor prognosis are inappropriate.
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Priorities to be considered intermediate are:
- A. the nonemergency, non-life-threatening needs of the client.
- B. those tasks that can be delegated to assistive personnel.
- C. those tasks that can be performed at the end of the shift.
- D. those task that can be performed at any time.
Correct Answer: A
Rationale: Priorities designated as intermediate by the nurse are those that are not urgent. They do not affect the client's immediate physiological status.
A client is admitted to the postpartum floor after a vaginal birth. Which finding indicates the need for immediate intervention?
- A. Lochia that soaks a perineal pad every 2 hours
- B. Persistent headache with blurred vision
- C. Red, painful nipple on one breast
- D. Strong-smelling vaginal discharge
Correct Answer: B
Rationale: Headache with blurred vision (B) suggests preeclampsia, a life-threatening condition requiring immediate intervention. Lochia (A), nipple pain (C), and discharge (D) are normal or less urgent postpartum findings.
The nurse is giving preoperative medication to an adult who is scheduled for surgery. The client says to the nurse that she does not want to have a transfusion during surgery because it is against her religion. The client has signed a consent form for surgery. How should the nurse respond?
- A. Explain that she has signed a consent form for surgery and that includes the use of transfusions if necessary
- B. Explain that the surgeon will probably not perform surgery if she won't have a transfusion
- C. Have the client sign an addendum to the operative permit excluding transfusions
- D. Withhold the medication and notify the physician
Correct Answer: C
Rationale: An addendum to refuse transfusions respects the client's religious beliefs, ensuring informed consent. Other responses dismiss her autonomy or delay care.
A 14 month-old had cleft palate surgical repair several days ago. The parents ask the nurse about feedings after discharge. Which lunch is the best example of an appropriate meal?
- A. Hot dog, carrot sticks, gelatin, milk
- B. Soup, blenderized soft foods, ice cream, milk
- C. Peanut butter and jelly sandwich, chips, pudding, milk
- D. Baked chicken, applesauce, cookie, milk
Correct Answer: B
Rationale: Soup, blenderized soft foods, ice cream, milk. In a child with cleft palate repair, parents should prepare soft foods and avoid those with particles that might traumatize the surgical site.
A client admitted with glaucoma is being treated with miotic (pilocarpine) eye drops. Following administration of the medication, the nurse will note:
- A. Dilation of the pupils
- B. Diminished redness of the sclera
- C. Decreased edema of the cornea
- D. Constriction of the pupils
Correct Answer: D
Rationale: Miotics, such as pilocarpine, are administered to the client with glaucoma to cause pupillary constriction, thereby lowering intraocular pressure. Answer A is incorrect because miotics constrict the pupil. Answer B is incorrect because miotics do not diminish redness. Answer C is incorrect because miotics do not decrease edema of the cornea.