Nokea
Two days after a nephrectomy, the client reports abdominal pressure and nausea, which assessment should the nurse implement?
- A. Palpate the abdomen
- B. Measure hourly urine output
- C. Ambulate client in hallway
- D. Auscultate bowel sounds
Correct Answer: D
Rationale: Auscultating bowel sounds helps assess for any bowel obstruction or ileus, which could be contributing to abdominal pressure.
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All of the following immune-mediated diseases are associated with antineutrophil cytoplasmic antibody, except
- A. Wegener granulomatosis
- B. Churg-Strauss syndrome
- C. Microscopic polyangiitis
- D. Henoch-Schönlein purpura
Correct Answer: D
Rationale: Henoch-Schönlein purpura is not associated with antineutrophil cytoplasmic antibodies (ANCA); it is an IgA-mediated vasculitis.
Congenital heart disease causing cyanosis without respiratory distress include EXCEPT
- A. tricuspid atresia
- B. aortic stenosis
- C. Ebstein anomaly
- D. pulmonary atresia
Correct Answer: B
Rationale: Tricuspid atresia, Ebstein anomaly, and pulmonary atresia can cause cyanosis without respiratory distress, while aortic stenosis typically does not.
Which clinical manifestation is included in toxic shock syndrome?
- A. Severe hypertension
- B. Subnormal temperature
- C. Erythematous macular rash
- D. Papular rash over extremities
Correct Answer: C
Rationale: One of the diagnostic criteria for toxic shock syndrome is a diffuse macular erythroderma. Hypotension is one of the manifestations. Fever of 38.9° C or higher is a characteristic. Desquamation of the palms and soles of the feet occurs in about 1 to 2 weeks.
An infant who has been in foster care since birth requires a blood transfusion. Who is authorized to give written, informed consent for the procedure?
- A. The foster mother
- B. The social worker who placed the infant in the foster home
- C. The registered nurse caring for the infant
- D. The nurse-manager
Correct Answer: A
Rationale: The foster mother, as the primary caregiver, is typically authorized to provide consent for medical procedures.
The MOST common cause of pulmonary hypertension in pediatric patients is
- A. idiopathic pulmonary hypertension
- B. pulmonary venoocclusive disease
- C. left-sided valvular heart disease
- D. chronic obstructive pulmonary disease
Correct Answer: A
Rationale: Idiopathic pulmonary hypertension is a rare but recognized cause of pulmonary hypertension in children.