Nokea
Which nursing actions are most appropriate to include in the care plan of a child with nephrotic syndrome? Select all that apply.
- A. Restricting the intake of protein
- B. Weighing the child daily
- C. Completing range-of-motion exercises
- D. Measuring abdominal circumference
- E. Collecting a 24-hour urine specimen
- F. Monitoring blood urea nitrogen (BUN) and creatinine levels
Correct Answer: B,C,D,E,F
Rationale: Daily weighing monitors fluid status, range-of-motion exercises prevent immobility complications, measuring abdominal circumference tracks ascites, collecting urine assesses proteinuria, and monitoring BUN/creatinine evaluates kidney function. Protein restriction is not typical.
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Pregnancy induced hypertension is diagnosed when:
- A. Hypertension is encountered after 20 weeks of gestation.
- B. Hypertension gets worse in first week of pregnancy.
- C. Hypertension is not controlled with aldomet.
- D. Hypertension gives rise to left ventricular failure.
- E. Blood urea & creatine levels in blood are abnormal.
Correct Answer: A
Rationale: Pregnancy-induced hypertension (gestational hypertension) is diagnosed when hypertension (BP ≥140/90 mmHg) appears after 20 weeks gestation without proteinuria or other preeclampsia features.
Because of the length of time the client must remain in skeletal traction, the nurse correctly assesses for evidence of skin breakdown in which area?
- A. Over the child's calves
- B. Over the child's scapulae
- C. On the child's knees
- D. On the child's buttocks
Correct Answer: D
Rationale: Prolonged immobility in traction increases pressure on the buttocks, a common site for skin breakdown due to constant contact with the bed.
Which of the following is a priority for the nurse to assess when testing the child's urine?
- A. Blood in the urine
- B. Bilirubin in the urine
- C. Ketones in the urine
- D. White blood cells in the urine
Correct Answer: C
Rationale: In DKA, assessing for ketones in the urine is a priority, as ketonuria confirms the presence of ketones, a hallmark of DKA resulting from fat metabolism due to insulin deficiency.
Because the burned child is confined to bed, the nurse assesses for footdrop. Which nursing action best prevents the development of footdrop?
- A. Apply braces to the feet and ankles.
- B. Keep the child in the side-lying position.
- C. Keep sheets tucked in at the foot of the bed.
- D. Rest the child's feet against a footboard.
Correct Answer: D
Rationale: Resting the child's feet against a footboard maintains the feet in a neutral position, preventing plantar flexion and footdrop during prolonged bed rest.
The nurse is caring for the infant in the neonatal ICU who has an umbilical artery catheter (UAC) in place. To monitor for and prevent complications with this catheter,which actions should be planned by the nurse? Select all that apply.
- A. Check the position marking on the catheter every shift.
- B. Position the tubing close to the infant’s lower limbs.
- C. Check for erythema or discoloration of the abdominal wall.
- D. Palpate for femoral,pedal,and tibial pulses every 2 to 4 hours.
- E. Reposition the catheter tubing every hour.
- F. Monitor blood glucose levels.
Correct Answer: A,C,D,F
Rationale: Check catheter position abdominal wall pulses every 2–4 hours and glucose levels to monitor for displacement bleeding perfusion issues or hypoglycemia. Keep tubing away from limbs and avoid frequent repositioning to reduce infection risk.