Nokea
An adult is receiving total parenteral nutrition. The nurse knows which of the following assessments is essential?
- A. Evaluation of the peripheral venous site
- B. Confirmation that the tube is in the stomach
- C. Assessment of the GI tract, including bowel sounds
- D. Fluid and electrolyte monitoring
Correct Answer: D
Rationale: For an adult receiving total parenteral nutrition (TPN), it is essential for the nurse to monitor fluid and electrolyte levels closely. TPN provides all essential nutrients, including fluids and electrolytes, directly into the bloodstream. Monitoring these levels is crucial to prevent potential complications such as fluid overload, electrolyte imbalances, and hyperglycemia. Assessing and maintaining appropriate fluid and electrolyte balance are essential components of managing a patient receiving TPN to ensure optimal patient outcomes.
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The serum alpha-fetoprotein (AFP) level is elevated with some malignant germ cell tumors (GCTs) especially endodermal sinus tumors; it can be used as a measure of treatment response and during follow-up after completion of chemotherapy. However, it is normally elevated during infancy. At which age does AFP physiologically fall to normal adult level?
- A. three month
- B. eight month
- C. one year
- D. three year
Correct Answer: C
Rationale: AFP levels typically normalize by around one year of age.
A 4-year-old weighing 15 kg produces 150 mL of urine in 10 hours. What should the nurse do?
- A. Notify the physician; urine output is too low.
- B. Encourage increased oral intake.
- C. Record the urine output in the chart.
- D. Administer IV fluids to rehydrate.
Correct Answer: C
Rationale: Expected urine output is 0.5-1 mL/kg/hr. For a 15-kg child over 10 hours, 75-150 mL is within normal limits.
Which of the following malignant tumors is least likely to occur in adults in comparison with children?
- A. acute Lymphoblastic Leukemia (ALL)
- B. osteosarcoma
- C. medulloblastoma
- D. retinoblastoma
Correct Answer: D
Rationale: Retinoblastoma predominantly occurs in children under 5 years of age, making it the least likely to occur in adults.
When assessing a client with autoimmune disorder, what signs should the nurse look for in the client?
- A. Hypotension
- B. Hives or rashes
- C. Localized inflammation
- D. Cramping and vomiting
Correct Answer: B
Rationale: When assessing a client with an autoimmune disorder, the nurse should look for signs such as hives or rashes. Autoimmune disorders can manifest with various skin manifestations, including hives or rashes, which may be indicative of an autoimmune response. These skin manifestations may occur due to the immune system mistakenly attacking the body's own tissues. Observing and monitoring these skin changes can help in assessing and managing the autoimmune disorder in the client. Additionally, localized inflammation may also be present in autoimmune disorders, but hives or rashes are more commonly associated with these conditions.
While examining a 2-year-old child, the nurse in charge sees that the anterior fontanel is open. The nurse should:
- A. Notify the doctor
- B. Look for other signs of abuse
- C. Recognize this as a normal finding
- D. Ask about a family history of Tay-Sachs disease
Correct Answer: C
Rationale: In infants and young children, it is normal for the anterior fontanel to remain open up to about 18-24 months of age. The fontanel serves an important function in allowing the skull to grow and expand as the brain grows rapidly during infancy. Therefore, the presence of an open fontanel in a 2-year-old child is a normal finding and does not warrant any immediate concern or action. It does not indicate abuse, the need to notify the doctor, or inquire about a family history of Tay-Sachs disease.