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During an assessment of a child admitted to the hospital with a probable diagnosis of nephrotic syndrome, what assessment findings should the nurse expect to observe? Select one that applies.
- A. Proteinuria
- B. Weight gain
- C. Decreased serum lipids
- D. Hematuria
Correct Answer: A
Rationale: In nephrotic syndrome, the hallmark finding is massive proteinuria due to increased glomerular permeability. This leads to hypoalbuminemia, resulting in generalized edema. Weight gain, not weight loss, is typically seen due to fluid retention. Serum lipids are elevated, not decreased, in nephrotic syndrome. Hematuria, the presence of blood in the urine, is not a typical finding in nephrotic syndrome.
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The nurse is caring for clients in the pediatric unit. A 6-year-old patient is admitted with 2nd and 3rd degree burns on his arms. The nurse should assign the new patient to which of the following roommates?
- A. A 4-year-old with sickle-cell disease
- B. A 12-year-old with chickenpox
- C. A 6-year-old undergoing chemotherapy
- D. A 7-year-old with a high temperature
Correct Answer: A
Rationale: The nurse should be concerned about the burn patient's vulnerability to infection due to compromised skin integrity. Sickle cell disease is not a communicable disease, so rooming the burn patient with a 4-year-old with sickle-cell disease would not pose an increased risk of infection transmission. Rooming the burn patient with a 12-year-old with chickenpox would increase the risk of infection for the burn patient. Rooming with a 6-year-old undergoing chemotherapy may expose the burn patient to potential infections. A 7-year-old with a high temperature could potentially have a contagious illness, which could be risky for the burn patient.
Following surgery to correct cryptorchidism, what is the priority action that the nurse should include in the plan of care?
- A. Prevent tension on the suture.
- B. Monitor urine for glucose and acetone.
- C. Encourage oral fluids, and monitor intake and output.
- D. Encourage coughing and deep breathing every hour.
Correct Answer: A
Rationale: The correct answer is to prevent tension on the suture. After surgery for cryptorchidism, the testicle is held in position by an internal suture that should not be dislodged. Immobilization of the area for a week is crucial to prevent complications like bleeding and infection. Monitoring urine for glucose and acetone is unrelated to this surgery. While maintaining hydration is important, forcing fluids is not necessary. Encouraging coughing and deep breathing every hour may be a postoperative consideration, but it is not the priority for this specific surgery.
A patient with a cast on the right leg is being cared for by a nurse. Which of the following assessment findings would be most concerning for the nurse?
- A. The capillary refill time is 2 seconds
- B. The patient complains of itching and discomfort
- C. The cast has a foul-smelling odor
- D. The patient is on antibiotics
Correct Answer: C
Rationale: A foul-smelling odor emanating from the cast is a concerning finding as it indicates the possibility of infection or the presence of a pressure ulcer. These conditions can lead to serious complications if not promptly addressed. It is crucial for the nurse to investigate further and take appropriate actions to prevent potential harm to the patient. The other options do not directly indicate a risk of infection or complications associated with the cast. Itching and discomfort are common complaints due to wearing a cast, and the patient being on antibiotics may be part of their treatment plan for an unrelated condition. Capillary refill time of 2 seconds is within the normal range and would not be a cause for immediate concern in this scenario.
An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse should place the infant in which best position at this time?
- A. Prone position
- B. On the stomach
- C. Left lateral position
- D. Right lateral position
Correct Answer: C
Rationale: After surgical repair of a cleft lip on the right side, the nurse should position the infant carefully to ensure comfort and prevent complications. Placing the infant in the prone position or on the stomach is not recommended as it may cause rubbing of the surgical site against the mattress. The optimal position for the infant is the left lateral position, away from the surgical repair site, to minimize the risk of trauma. Placing the infant on the right lateral position would be contraindicated as it is on the side of the repair. Additionally, positioning the infant upright on the back can help prevent airway obstruction by secretions, blood, or the tongue. Therefore, the correct choice is to place the infant in the left lateral position to promote safety and comfort post cleft lip surgery.
The mother of a newborn infant with hypospadias asks the nurse why circumcision cannot be performed. Which is the most appropriate response by the nurse?
- A. Circumcision will cause an infection.
- B. Circumcision is not performed in a newborn.
- C. Circumcision will cause difficulty with urination.
- D. Circumcision has been delayed to save tissue for surgical repair.
Correct Answer: D
Rationale: The reason circumcision is not performed in a newborn with hypospadias is that the dorsal foreskin tissue will be needed for the surgical repair of hypospadias. Delaying circumcision allows for the preservation of tissue that will be crucial for the corrective surgery. This surgical repair is typically done within the first year of life to minimize the psychological impact on the child. Choices A, B, and C are incorrect as they do not address the specific reason for delaying circumcision in this case.