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A nurse aide is taking care of a 2 year-old child with Wilm's tumor. The nurse aide asks the nurse why there is a sign above the bed that says DO NOT PALPATE THE ABDOMEN? The best response by the nurse would be which of these statements?
- A. Touching the abdomen could cause cancer cells to spread.'
- B. Examining the area would cause difficulty to the child.'
- C. Pushing on the stomach might lead to the spread of infection.'
- D. Placing any pressure on the abdomen may cause an abnormal experience.'
Correct Answer: A
Rationale: Manipulation of the abdomen can lead to dissemination of cancer cells to nearby and distant areas. Bathing and turning the child should be done carefully.
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Postoperative orders for a client undergoing a mitral valve replacement include monitoring pulmonary artery pressure together with pulmonary capillary wedge pressure with a pulmonary artery catheter. The purpose of these actions by the nurse is to assess
- A. Right ventricular pressure
- B. Left ventricular end-diastolic pressure
- C. Acid-base balance
- D. Coronary artery stability
Correct Answer: B
Rationale: Left ventricular end-diastolic pressure. The pulmonary capillary wedge pressure is reflective of left ventricular end-diastolic pressure, assessing the heart's ability to pump effectively.
The nurse is providing home care for a client with heart failure and pulmonary edema. Which nursing diagnosis should have priority in planning care?
- A. Impaired skin integrity related to dependent edema
- B. Activity intolerance related to oxygen supply and demand imbalance
- C. Constipation related to immobility
- D. Risk for infection related to ineffective mobilization of secretions
Correct Answer: B
Rationale: Activity intolerance related to oxygen supply and demand imbalance. This is the primary problem due to decreased cardiac output related to heart failure. There is a reduction of oxygen, leading to findings of dyspnea and fatigue.
Which test for diabetes measures the long-term management of the disease?
- A. Fasting blood sugar
- B. Glucose tolerance test
- C. Finger stick glucose test
- D. Glycosylated hemoglobin
Correct Answer: D
Rationale: Glycosylated hemoglobin (HbA1c) measures average blood glucose over 2-3 months, assessing long-term diabetes control, unlike fasting, tolerance, or finger stick tests, which are short-term.
While planning care for a 2 year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior?
- A. Strange bed and surroundings
- B. Separation from parents
- C. Presence of other toddlers
- D. Unfamiliar toys and games
Correct Answer: B
Rationale: Separation from parents. Separation anxiety is the greatest stress for a toddler during hospitalization.
A practical nurse is collaborating with a registered nurse educator to develop materials for a hospital-wide campaign about zero tolerance for lateral violence and bullying among staff. Which actions should staff members be encouraged to perform if they experience workplace violence? Select all that apply.
- A. Document the interactions with the bully
- B. Ignore the bully's comments, remarks, and allegations
- C. Observe interactions between the bully and other colleagues
- D. Report the violent incidents to the hospital administrator
- E. Tell the bully you will not tolerate the unprofessional behavior
Correct Answer: A, C, D, E
Rationale: Documenting incidents (A), observing patterns (C), reporting to administration (D), and confronting unprofessional behavior (E) are proactive steps to address bullying. Ignoring comments (B) may allow the behavior to persist.