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After a child undergoes nephrectomy for a Wilms' tumor, the nurse should assess the child postoperatively for which early sign of a complication?
- A. Increased abdominal distention.
- B. Elevated blood pressure.
- C. Increased respiratory rate.
- D. Increased urine output.
Correct Answer: A
Rationale: Distention suggests internal bleeding.
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The nurse is assessing the infant shown in the figure. On observing the client from this angle, the nurse should document that this infant has which of the following?
- A. Ortolani’s “click.”
- B. Limited abduction.
- C. Galeazzi’s sign.
- D. Asymmetric gluteal folds.
Correct Answer: D
Rationale: This infant with congenital hip dysplasia has asymmetric gluteal folds. The Ortolani “click” occurs when the nurse feels the femur sliding into the acetabulum with a “click.” Limited abduction may be observed during an attempt to abduct the infant’s thighs. Galeazzi’s sign reveals femoral foreshortening and is observed by fl exing the thighs.
A parent asks the nurse about head lice (pediculosis capitis) infestation during a visit to the clinic. Which of the following symptoms should the nurse tell the parent is most common in a child infected with head lice?
- A. Itching of the scalp.
- B. Scaling of the scalp.
- C. Serous weeping on the scalp surface.
- D. Pinpoint hemorrhagic spots on the scalp surface.
Correct Answer: A
Rationale: Itching is the hallmark symptom of head lice due to an allergic reaction to lice saliva.
A nurse is reviewing a hospital's protocol for managing pediatric ingestions. Which step should be prioritized in the protocol?
- A. Administer an antidote immediately.
- B. Obtain a detailed history of the ingestion.
- C. Perform a physical examination.
- D. Order laboratory tests.
Correct Answer: B
Rationale: A detailed history (substance, amount, time) guides management decisions. Antidotes, exams, or labs follow based on history findings.
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.
The health care team has noticed an increase in I.V. infiltrations on the pediatric floor. As part of a Plan, Do, Study, Act quality improvement plan the team should do the following in which order?
- A. Analyze the data.
- B. Decide to monitor I.V. gauges.
- C. Perform chart audits.
- D. Write a new I.V. insertion policy.
Correct Answer: B,C,A,D
Rationale: The PDSA cycle involves planning (deciding to monitor), doing (chart audits), studying (analyzing data), and acting (writing a new policy).