Nokea
While performing daily peritoneal dialysis and catheter exit site care with the mother of a child with chronic renal failure, which of the following would be an important step to emphasize to the mother?
- A. Applying an occlusive dressing after cleaning the site.
- B. Changing the dressing when the peritoneal space is dry.
- C. Examining the site for signs of infection while cleaning the area.
- D. Pulling on the catheter to hold taut while cleaning the skin.
Correct Answer: C
Rationale: Checking for signs of infection is crucial.
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The physician is able to reduce an infant's hernia and schedules the infant for a herniorrhaphy in 2 days. The mother asks the nurse why the surgery is not performed now. Which of the following responses indicates that the nurse understands the rationale for delaying the surgery?
- A. Delaying the surgery ensures that your infant will receive the proper preoperative preparation.
- B. The infant can take nothing by mouth for at least 24 hours before the surgery.
- C. Waiting these 2 days helps to allow any edema and inflammation in the area to subside.
- D. Your infant needs to wear a truss for at least 24 hours before any surgery can be attempted.
Correct Answer: C
Rationale: Delaying surgery allows edema and inflammation to decrease, improving surgical outcomes.
Which of the following assessment findings should alert the nurse to suspect appendicitis in a male adolescent complaining of severe abdominal pain?
- A. Abdomen appears slightly rounded.
- B. Bowel sounds are heard twice in 2 minutes.
- C. All four abdominal quadrants reveal tympany.
- D. The client demonstrates a cremasteric reflex.
Correct Answer: B
Rationale: Decreased bowel sounds suggest appendicitis due to peritoneal irritation.
While assessing a preschooler brought by her parents to the emergency department after ingestion of kerosene, the nurse should be alert for which of the following?
- A. Uremia.
- B. Hepatitis.
- C. Carditis.
- D. Pneumonitis.
Correct Answer: D
Rationale: Kerosene ingestion often causes chemical pneumonitis due to aspiration risk. Uremia, hepatitis, and carditis are not common complications.
A 10-year-old with leukemia is taking immunosuppressive drugs. To maintain health the nurse should instruct the child and parents to:
- A. Continue with immunizations.
- B. Not receive any live attenuated vaccines.
- C. Receive vitamin and mineral supplements.
- D. Stay away from peers.
Correct Answer: B
Rationale: Live attenuated vaccines are contraindicated in immunosuppression due to infection risk. Other options are unnecessary or overly restrictive.
When developing the teaching plan about illness for the mother of a preschooler, which of the following should the nurse include about how a preschooler perceives illness?
- A. A necessary part of life.
- B. A test of self-worth.
- C. A punishment for wrongdoing.
- D. The will of God.
Correct Answer: C
Rationale: Preschoolers often view illness as punishment for bad behavior due to magical thinking.