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A nurse is collecting data from a 1-year-old child who has Wilms' tumor. Which of the following findings should the nurse expect?
- A. Diarrhea
- B. Jaundice
- C. Swollen joints
- D. Abdominal mass
Correct Answer: D
Rationale: Wilms' tumor often presents as an asymptomatic abdominal mass.
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A nurse is preparing a 9-year-old child for an IV catheter insertion. Which of the following actions should the nurse take first?
- A. Ask the child what he knows about the procedure.
- B. Allow the child to see and touch IV tubing and supplies.
- C. Describe the procedure using visual aids.
- D. Explain to the child's parents what role they will have during the procedure.
Correct Answer: A
Rationale: Understanding the child's knowledge and feelings about the procedure helps tailor the explanation to address any misconceptions and reduce anxiety.
A nurse is preparing to administer acetaminophen 15 mg/kg PO to a preschool child for fever. The child weighs 30 lb. Available is acetaminophen liquid 160 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 6.4 mL
- B. 5.4 mL
- C. 7.4 mL
- D. 4.4 mL
Correct Answer: 6.4
Rationale: Calculation: 30 lb × 0.454 kg/lb = 13.62 kg; 15 mg/kg × 13.62 kg = 204.3 mg; 204.3 mg ÷ 160 mg/5 mL = 6.4 mL.
A nurse is collecting data from a child who has sickle disease and is experiencing a vaso-occlusive crisis. Which of the following findings should the nurse expect?
- A. Pain
- B. Vomiting
- C. Constipation
- D. Bradycardia
Correct Answer: A
Rationale: Pain is the most common and significant symptom of a vaso-occlusive crisis in sickle cell disease.
A nurse in a family health clinic is collecting data as part of a routine physical examination of a client who is about to enter high school. The nurse observes an abnormal lateral curvature of the spine. The nurse should expect the provider to document which of the following disorders?
- A. Scoliosis
- B. Ankylosis
- C. Kyphosis
- D. Lordosis
Correct Answer: A
Rationale: Scoliosis is characterized by an abnormal lateral curvature of the spine.
A nurse is assisting with the admission of a 2-year-old toddler who has acute gastroenteritis. Which of the following actions should the nurse take first?
- A. Determine if the toddler is voiding.
- B. Request evaluation of the toddler's serum electrolytes.
- C. Initiate isotonic fluids with 20 mEq/L potassium chloride.
- D. Collect a stool sample from the toddler.
Correct Answer: A
Rationale: Assessing urine output is crucial for determining the child's hydration status. Voiding is an important indicator of kidney function and fluid balance.