NCLEX Practice Questions — Set 46
How to use this set
Run it as a timed block rather than dipping in and out. 100 items at roughly a minute each is close to the pace the real exam asks for, and pacing is a skill that only improves under a clock. Answer every item before you open a single rationale — checking as you go turns a test into a reading exercise and hides the questions you were unsure about.
These sets are numbered rather than sorted by subject. The questions come from a general NCLEX bank that carries no topic field, and labelling them by eye would put a share of them under the wrong heading, so they are presented as mixed sets — which is how the exam itself arrives.
The 100 questions
A client who follows a vegetarian diet was referred to a dietitian for nutritional counseling for anemia. Which client outcome indicates that the client does not understand nutritional counseling? The client:
Show answer and rationale
Correct answer: A. Drinks coffee or tea with meals.
Coffee and tea increase gastrointestinal motility and inhibit the absorption of nonheme iron. Clients are instructed to add dried fruits to dishes at every meal because dried fruits are a nonheme or nonanimal iron source. Cooking in iron cookware, especially acid-based foods such as tomatoes, adds iron to the diet. Clients are instructed to add a rich supply of vitamin C to every meal because the absorption of iron is increased when food with vitamin C or ascorbic acid is consumed.
After teaching the parents of an infant diagnosed with Hirschsprung’s disease, the nurse determines that the parents understand the diagnosis when the father states which of the following?
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Correct answer: B. "The nerves at the end of the large colon are missing."
The primary defect in Hirschsprung’s disease is an absence of autonomic parasympathetic ganglion cells in the distal portion of the colon. Thus, the nerves at the end of the large colon are missing. Absence of a rectal opening refers to an imperforate anus. A tube between the trachea and esophagus refers to a tracheoesophageal fistula. Presence of a tight muscle below the stomach refers to pyloric stenosis.
A health care provider prescribes 0.5 mg of protamine sulfate for a client who is showing signs of bleeding after receiving a 100-unit dose of heparin. The nurse should expect the effects of the protamine sulfate to be noted in which of the following time frames?
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Correct answer: D. 30 minutes.
A dose of 0.5 mg of protamine sulfate reverses a 100-unit dose of heparin within 20 minutes. The nurse should administer protamine sulfate by IV push slowly to avoid adverse effects, such as hypotension, dyspnea, bradycardia, and anaphylaxis.
An infant diagnosed with Hirschsprung’s disease undergoes surgery with the creation of a temporary colostomy. Which of the following statements by the parent regarding the colostomy indicates the need for further teaching?
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Correct answer: A. "The colostomy will give time for the nerves to return to normal."
The goal of the surgery is to remove the aganglionic portion of the intestine. The remaining intestines should have normal innervation. Colostomies are used to relieve the obstruction and allow the remaining intestines to return to normal size. A temporary loop or double-barreled colostomy has stomas for both the proximal and distal portion of the bowel. The final surgical repair is usually done when the infant is around 20 lb (9.1 kg). A new stoma is frequently swollen and bruised after surgery.
When teaching the mother of an infant who has received a temporary colostomy for treatment of Hirschsprung’s disease about how the stoma should normally appear, which of the following descriptions about the stoma’s appearance should the nurse include in the teaching?
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Correct answer: A. Staying deep red in color.
Typically, the stoma should remain deep red in color as long as the infant has the colostomy. A dark red to purplish color may indicate impaired circulation to the stoma.
When teaching the parent of an infant with Hirschsprung’s disease who received a temporary colostomy about the types of foods the infant will be able to eat, which of the following would the nurse recommend?
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Correct answer: C. Regular diet.
A regular diet would be recommended for the child with a colostomy; no special diet is needed. High-fiber foods, such as fruits and vegetables, should be minimized because they increase the bulk in the stool. Fat is necessary for brain growth in the first year of life. A high-residue diet would result in bulkier stools and increased gas production, which will collect in the colostomy bag. Therefore, a high-residue diet is not indicated.
An infant with Hirschsprung’s disease is to be discharged 1 or 2 days after surgery to create a colostomy. After teaching the infant’s parents about the overall effects of their infant’s surgery, the nurse determines that the teaching has been effective when the parents state which of the following?
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Correct answer: A. "When he’s ready, toilet training may be difficult."
Toilet-training is commonly more difficult for children who have undergone surgery for Hirschsprung’s disease than it is for other children. This is because of the trauma to the area and the associated psychological implications. Abdominal distention is an early sign of infection and therefore the parents need to report it to the primary care provider. Typically, dietary restrictions are not required. Usually the infant is placed on an age-appropriate diet. Vitamin supplementation is not necessary if the infant’s dietary intake is adequate.
A nurse is caring for a 10-month-old, weighing 8.0 kg, who was admitted for dehydration. The infant has vomited five times in the last 3 hours and has had no wet diapers in the last 8 hours. The nurse informs the primary health care provider. Which of the following prescriptions should the nurse question?
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Correct answer: B. Strict intake and output; weighing all diapers.
The infant is in need of a fluid bolus. A fluid bolus should consist of an isotonic fluid such as normal saline or lactated ringers. Dextrose 25% is not an appropriate bolus for dehydrated children because it could cause a fluid shift that may result in cerebral edema and death. D5 .45% normal saline is an appropriate IV fluid for infants. The rate is 1.5 times maintenance for this child and is appropriate for the first 24 hours if the child is dehydrated. Once hydration is adequate, the infant’s IV rate should be reduced to a maintenance rate. Vomiting is persistent, so it is appropriate for the child to be NPO. Strict I and O is an appropriate prescription for all dehydrated children.
A child is admitted with a tentative diagnosis of shigella. The nurse should do which of the following?
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Correct answer: C. All of the above
Shigella is caused by the Shigella organism. Clinical manifestations of shigella include fever, nausea and vomiting, some cramping, headache, seizures, rectal prolapse, and loose, watery stools containing pus, mucus, and blood. The nurse should assess the child for these symptoms on an ongoing basis. Shigella is spread via direct contact with the organism, which is found in the stool. A stool specimen will show increased numbers of WBCs, blood, and mucus. Vomiting and loose stools can result in severe dehydration and electrolyte imbalance. Thus, the nurse should record intake, output, and daily weights. There is no need for strict isolation; masks are not needed as shigella is not transmitted by airborne methods.
Which of the following would most likely alert the nurse to the possibility that a preschooler is experiencing moderate dehydration?
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Correct answer: C. Absence of tear formation.
The absence of tears is typically found when moderate dehydration is observed as the body attempts to conserve fluids. Other typical findings associated with moderate dehydration include a dry mouth, sunken eyes, poor skin turgor, and an increased pulse rate. Deep, rapid respirations are associated with severe dehydration. Decreased perspiration, not diaphoresis, would be seen with moderate dehydration. The specific gravity of urine increases with decreased output in the presence of dehydration.
Which of the following would be an important assessment finding for an 8-month-old infant admitted with severe diarrhea?
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Correct answer: A. Depressed anterior fontanel.
An infant with severe diarrhea will experience some degree of dehydration. In an 8-month-old child, the anterior fontanel has not closed. Therefore, a depressed anterior fontanel would be an important finding. Additionally, the infant would exhibit dry mucous membranes, lethargy, hyperactive bowel sounds, dark urine, and sunken eyeballs. Skin turgor would be decreased or delayed (eg, slow to return when pinched). Bowel sounds every 5 seconds would not be considered abnormal for an infant.
Which of the following would be the best activity for the nurse to include in the plan of care for an infant experiencing severe diarrhea?
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Correct answer: B. Weighing the infant each day.
Because an infant experiencing severe diarrhea is at high risk for a fluid volume deficiency, the nurse needs to evaluate the infant’s fluid balance status by weighing the infant at least every day. Body weight is the best indicator of hydration status because a higher proportion of an infant’s body weight is water, compared with an adult. Initially, the infant with severe diarrhea is not allowed liquids but is given fluids intravenously. Therefore, monitoring the oral intake of formula is inappropriate. Although checking the anterior fontanel for depression or bulging provides information about hydration status, this method is not considered the best indicator of the infant’s fluid balance. Monitoring skin turgor can provide information about fluid volume status. The abdomen is commonly used to assess skin turgor in an infant because it is a large surface area and can be accessed quickly. However, weight is the best indicator of fluid balance.
A 3-year old with dehydration has vomited three times in the last hour and continues to have frequent diarrhea stools. The child was admitted 2 days ago with gastroenteritis caused by rotavirus. The child weighs 22 kg, has a normal saline lock in his right hand, and has had 30 mL of urine output in the last four hours. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the primary health care provider with the recommendation for:
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Correct answer: B. Starting a fluid bolus of normal saline.
The child is dehydrated, is not able to retain oral fluids, and continues to have diarrhea. A normal saline bolus should be given followed by maintenance of IV fluids. Antidiarrheal medications are not recommended for children and will prolong the illness. The child has gastroenteritis caused by a viral illness. IV antibiotics are not indicated for viral illnesses. Strict I&O is important in all children with gastroenteritis.
Which of the following would be most appropriate for the nurse to teach the mother of a 6-month-old infant hospitalized with severe diarrhea to help her comfort her infant who is fussy?
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Correct answer: B. Offering a pacifier.
Typically, an infant hospitalized with severe diarrhea receives fluid replacement intravenously rather than orally. Oral fluids and food are usually withheld. Although activities such as placing a mobile over the crib, speaking to the infant, or turning on the television may provide distraction for or help in calming the infant, a fussy infant receiving nothing by mouth is usually best comforted by providing a pacifier to satisfy sucking needs.
Which of the following would be appropriate for the nurse to identify as a priority nursing problem for an infant just admitted to the hospital with a diagnosis of gastroenteritis?
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Correct answer: C. Deficient fluid volume related to excessive losses from severe diarrhea.
Given this infant’s history of gastroenteritis, the priority problem would be fluid volume deficit. With gastroenteritis, vomiting and diarrhea occur, leading to the loss of fluids. This loss of fluids is problematic in infants because a higher proportion of their body weight is water. Pain is not a priority problem, although the nurse should continue to assess the infant for pain. There are no data to indicate impaired parenting. Impaired urinary elimination is related to the infant’s fluid volume deficit resulting from vomiting and diarrhea associated with gastroenteritis. If the infant’s fluid volume deficit is not corrected, then this nursing diagnosis may become the priority.
The nurse teaches the father of an infant hospitalized with gastroenteritis about the next step of the treatment plan once the infant’s condition has been controlled. The nurse determines that the father understands when he explains which of the following will occur with his infant?
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Correct answer: A. The infant will receive clear liquids for a period of time.
The usual way to treat an infant hospitalized with gastroenteritis is to keep the infant nothing-by-mouth status to rest the gastrointestinal tract. The resulting fluid volume deficit is treated with intravenous fluids. When the infant’s condition is controlled (eg, when vomiting subsides), clear liquids are then started slowly. Formula and juice will be started once the infant’s vomiting has subsided and the infant has demonstrated the ability to tolerate clear liquids for a period of time. In this situation, there is no need to test the infant’s blood every day for anemia. Most likely, the infant’s serum electrolyte levels would be monitored closely. Typically, an infant is placed in a private room because gastroenteritis is most commonly caused by a virus that is easily transmitted to others.
The mother of a toddler who has just been admitted with severe dehydration secondary to gastroenteritis says that she cannot stay with her child because she has to take care of her other children at home. Which of the responses by the nurse would be most appropriate?
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Correct answer: C. "I understand, but feel free to visit or call anytime to see how your child is doing."
The nurse’s best course of action would be to support the mother. This is best done by conveying understanding and encouraging the mother to visit or call. Telling the mother that she shouldn’t leave and that the child is very sick is critical and insensitive. Additionally, it implies guilt should the mother leave. Commenting that the child does not need anyone is not appropriate or true. Toddlers, in particular, need family members present because of the stresses associated with hospitalization. They experience separation anxiety, a normal aspect of development, and need constancy in their environment. Asking the mother to find someone else to stay with her children is inappropriate. The children at home also need the support of the mother and/or other family members to minimize the disruptions in family life resulting from the toddler’s hospitalization and to maintain consistency.
A 9-month-old is admitted because of dehydration. How should the nurse go about accurately monitoring fluid intake and output?
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Correct answer: C. All of the above
Accurate intake and output recording includes noting all intake, including IV fluids; noting output, such as emesis and stool; weighing diapers; measuring weight daily; measuring urine specific gravity; monitoring serum electrolytes; and monitoring for signs of dehydration. Children who are dehydrated must receive sufficient fluid intake, but having a breast-feeding child switch to bottle-feeding will not promote intake. Restricting fluids just prior to weighing the child will not alter the accuracy of the weight, and the nurse should continue to encourage fluids for this dehydrated child.
The primary care provider prescribes intravenous fluid replacement therapy with potassium chloride to be added for a child with severe gastroenteritis. Before adding the potassium chloride to the intravenous fluid, which of the following assessments would be most important?
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Correct answer: C. Ability to void.
Potassium chloride is readily excreted in the urine. Before adding potassium chloride to the IV fluid, the nurse should ascertain whether the child can void; if not, potassium chloride may build up in the serum and cause hyperkalemia. An electrocardiogram could be done during intravenous potassium replacement therapy to evaluate for these changes. Having a stool daily is important but, because potassium is primarily excreted in the urine, the child’s ability to void must be verified. Serum calcium levels do not indicate the child’s ability to tolerate potassium replacement.
Which of the following would alert the nurse to suspect that a child with severe gastroenteritis who has been receiving intravenous therapy for the past several hours may be developing circulatory overload?
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Correct answer: B. Auscultation of moist crackles.
An early sign of circulatory overload is moist rales or crackles heard when auscultating over the chest wall. Elevated blood pressure, engorged neck veins, a wide variation between fluid intake and output (with a higher intake than output), shortness of breath, increased respiratory rate, dyspnea, and cyanosis occur later.
The stool culture of a child with profuse diarrhea reveals Salmonella bacilli. After teaching the mother about the course of Salmonella enteritidis, which of the following statements by the mother indicates effective teaching?
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Correct answer: A. "Some people become carriers and stay infectious for a long time."
After having S. enteritidis, some clients become chronic carriers of the causative organism and remain infectious for a long time as the organism continues to be shed from the body. During this time, the child is still considered infectious. No antitoxin is available to treat or prevent Salmonella infections.
A child is started on a soft diet after having been on clear liquids following an episode of severe gastroenteritis. When helping the mother choose foods for her child, which of the following foods would be most appropriate?
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Correct answer: C. Bananas and rice cereal.
After clear liquids, the foods of choice are soft foods. These foods should be easily digested and low in fat. Additionally, the foods should be nonbulk-forming. Bananas and rice cereal are low in fat and easy to digest. Muffins and eggs, as well as sausage and pancakes, are typically high in fat and would be avoided. Although a bagel is low in fat, bran cereal is high in fiber and would be avoided because it may cause more diarrhea.
A child undergoes rehydration therapy after having diarrhea and dehydration. A nurse is teaching the child’s parents about dietary management. The nurse understands that the teaching plan has been successful when the parents tell the nurse that they will follow which type of diet?
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Correct answer: B. Regular.
Dietary management following rehydration for diarrhea and mild dehydration would include offering the child a regular diet. Following rehydration, there is no need for the child to be on a special diet, such as a clear liquid, full liquid, or soft diet.
When obtaining a history from the parents of a child diagnosed with diarrhea due to Salmonella, the nurse should ask the parents if the child has been exposed to which of the following possible sources of infection?
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Correct answer: A. Undercooked eggs.
Diarrhea related to Salmonella bacilli is commonly spread by raw or undercooked fowl and eggs, pet turtles, and kittens. Food poisoning caused by Staphylococcus species is commonly spread by inadequately cooked or refrigerated custards, cream fillings, or mayonnaise. Psittacosis, a respiratory illness, may be spread by canaries. Contaminated, unwashed fruit is associated with typhoid fever (caused by Salmonella typhi), a disorder rarely seen in the United States.
On a home visit following discharge from the hospital after treatment for severe gastroenteritis, the mother tells the nurse that her toddler answers "No!" and is difficult to manage. After discussing this further with the mother, the nurse explains that the child’s behavior is most likely the result of which of the following?
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Correct answer: A. Expression of individuality.
The "no" behavior demonstrated by a toddler is typical of this age group as the child attempts to be self-assertive as an individual. The negativism does not demonstrate an inherited personality trait or disinterest. Rather, it reflects the developmental task of establishing autonomy. The toddler is attempting to exert control over the environment. It is too early to assess leadership qualities in a toddler.
The mother of a toddler hospitalized for episodes of diarrhea reports that when her toddler cannot have things the way she wants, she throws her legs and arms around, screams, and cries. The mother says, "I don’t know what to do!" After teaching the mother about ways to manage this behavior, which of the following statements indicates that the nurse’s teaching was successful?
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Correct answer: D. "Next time she screams and throws her legs, I’ll ignore the behavior."
The child is demonstrating behavior associated with temper tantrums, which are relatively frequent normal occurrences during toddlerhood as the child attempts to develop a sense of autonomy. The development of autonomy requires opportunities for the child to make decisions and express individuality. Ignoring the outbursts is probably the best strategy. Doing so avoids rewarding the behavior and helps the child to learn limits, promoting the development of self-control. However, the mother should intervene in a temper tantrum if the child is likely to injure herself. Allowing the child to have what she wants occasionally would typically add to the problems associated with temper tantrums, because doing so rewards the behavior and prevents the child from developing self-control. Toddlers do not possess the capacity to understand explanations about behavior. Expressing disappointment in the child’s behavior or telling her that she is being a bad girl reinforces feelings of guilt and shame, thus interfering with the child’s ability to develop a sense of autonomy.
The mother of a toilet-trained toddler who was admitted to the hospital for severe gastroenteritis and subsequent dehydration and is now at home asks the nurse why the child still wets the bed. Which of the following should be the nurse’s best response?
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Correct answer: C. "Hospitalization is a traumatic experience for children. Regression is common and it takes time for them to return to their former behavior."
Hospitalization is a traumatic time for a child, and it takes some time to readjust to the home environment. The child may regress at home for a period until she feels comfortable. Children normally do not dislike their home environment; in fact, they usually are eager to get home to familiar surroundings where they feel safe.
A client was admitted to the hospital with iron deficiency anemia and blood-streaked emesis. Which question is most appropriate for the nurse to ask in determining the extent of the client’s activity intolerance?
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Correct answer: A. "What daily activities were you able to do 6 months ago compared with the present?"
It is difficult to determine activity intolerance without objectively comparing activities from one time frame to another. Because iron deficiency anemia can occur gradually and individual endurance varies, the nurse can best assess the client’s activity tolerance by asking the client to compare activities 6 months ago and at present. Asking a client how long a problem has existed is a very open-ended question that allows for too much subjectivity for any definition of the client’s activity tolerance. Also, the client may not even identify that a "problem" exists. Asking the client whether he is staying abreast of usual activities addresses whether the tasks were completed, not the tolerance of the client while the tasks were being completed or the resulting condition of the client after the tasks were completed. Asking the client if he is more tired now than usual does not address his activity tolerance. Tiredness is a subjective evaluation and again can be distorted by factors such as the gradual onset of the anemia or the endurance of the individual.
A child is admitted with a diagnosis of possible appendicitis. The child is in acute pain. Which of the following nursing interventions would be appropriate prior to surgery to decrease pain?
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Correct answer: C. All of the above
Cold is a vasoconstrictor and supplies some degree of anesthesia. The child is usually more comfortable on his side with his legs flexed to take the strain off the inflamed appendix. Limiting the child’s activity puts less stress on the inflamed appendix and lessens the discomfort. Heat increases circulation to an area, causing more engorgement and pain and, possibly, rupture of the appendix. Heat is contraindicated in any situation where rupture or perforation is a possibility. A cathartic is contraindicated when appendicitis is suspected. Increasing peristalsis can cause the appendix to rupture.
A 10-year old male is 24 hours postappendectomy. He is awake, alert, and oriented. He tells the nurse that he is experiencing pain. He has a prescription for morphine 1 to 2 mg PRN pain. What is the priority nursing action in managing the child’s pain?
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Correct answer: C. Obtain vital signs with a pain score.
The child is in pain and needs intervention but before the nurse can determine how to proceed, it is essential to know the client’s pain score to determine the appropriate morphine dose. In addition, the nurse cannot evaluate the effectiveness of the pain medication if there is no pain score prior to administering the medication. Changing the child’s position and administering pain medication may be helpful to relieve the child’s pain but the nurse must first know the severity of the pain before determining the appropriate intervention. The nurse must perform a head to toe assessment however it is not the priority in managing the child’s pain.
A 5-year-old child is experiencing pain after an appendectomy. Which data collection tool should the nurse use to assess the pain?
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Correct answer: D. FACES pain rating scale.
The nurse should use the FACES pain rating scale for children aged three or older. The visual analog and numerical scales are used with adults. The FLACC (faces-legs-activity-cry-consolability) scale is a behavioral scale that is appropriate for very small children or nonverbal children.
A 7-year-old has had an appendectomy on November 12. He has had pain for the last 24 hours. There is a prescription to administer Tylenol (acetaminophen) with Codeine every 3 to 4 hours as needed. The nurse is beginning the shift and the child is requesting pain medication. The nurse reviews the chart below for pain history. Based on the information in the chart, what should the nurse do next?
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Correct answer: A. Administer the Tylenol with Codeine.
The nurse should administer the Tylenol with Codeine as the client indicates he is having pain. Although the child reports less severe pain, he is still experiencing pain. The nurse will also want the child to have less pain because he will need to be more active during the day. Assessing the child later will likely cause the pain to have increased and be more difficult to manage. While distraction is appropriate for short-term pain, such as from a needlestick or pain that the child might be able to manage himself, postoperative pain should be relieved with medication.
When obtaining the initial health history from a 10-year-old child with abdominal pain and suspected appendicitis, which of the following questions would be most helpful in eliciting data to help support the diagnosis?
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Correct answer: C. "Where did the pain start?"
The most helpful question would be to determine the location of the pain when it started. The pain associated with appendicitis usually begins in the periumbilical area, and then progresses to the right lower quadrant. After the nurse has determined the location of the pain, asking about what was done for the pain would be appropriate. Asking about the child’s usual bowel movement pattern is a general question unrelated to child’s condition. Children with appendicitis may have diarrhea or constipation. Additionally, knowledge about the child’s usual pattern would not be a priority because the child with appendicitis typically is not hospitalized long enough to reestablish the normal pattern. Although the characteristics of the pain are important, asking if the pain is continuous or intermittent is vague and general because the pain could be associated with numerous conditions. With appendicitis, the client’s pain may begin as intermittent, but it eventually becomes continuous.
When developing the plan of care for a school-age child with a suspected diagnosis of appendicitis who has severe abdominal pain, which of the following measures should the nurse expect to include in the child’s plan of care?
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Correct answer: D. Application of an ice bag.
Application of an ice bag may help to relieve pain by decreasing circulation to the area. A heating pad is contraindicated because heat may increase circulation to the appendix, possibly leading to rupture. Rectal tubes are contraindicated because they stimulate bowel motility and can exacerbate abdominal pain. Also, they would be ineffective because accumulation of gas in the lower bowel is not likely to be the cause of the child’s discomfort. Because narcotics can mask the child’s symptoms, such as pain and discomfort, and they also decrease bowel motility, they are not given until after a definitive diagnosis has been made.
Which of the following assessment findings should alert the nurse to suspect appendicitis in a male adolescent with severe abdominal pain?
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Correct answer: C. Bowel sounds are heard twice in 2 minutes.
Manifestations of appendicitis include decreased or absent bowel sounds. Normally, bowel sounds are heard every 10 to 30 seconds. Therefore, bowel sounds heard twice in 2 minutes suggests appendicitis. Normally, the contour of the male adolescent abdomen is flat to slightly rounded, and tympany is typically heard when auscultating over most of the abdomen. A cremasteric reflex is normal for male adolescents.
Which of the following should be the priority assessment for an adolescent on return to the nursing unit after an appendectomy?
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Correct answer: D. The dressing on the surgical site.
The priority assessment after an appendectomy would be the dressing over the surgical site to determine whether there is any drainage or bleeding. The surgical dressing should be clean, dry, and intact. Once the dressing has been assessed, the nurse would assess the intravenous infusion site, assess the NG tube to be sure it is functioning, and finally, determine the degree of pain the client is experiencing.
An adolescent who has had an appendectomy and developed peritonitis has nausea. Which of the following should the nurse do first?
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Correct answer: D. Irrigate the nasogastric (NG) tube.
After an appendectomy, the client who develops peritonitis typically has an NG tube in place. When a client has nausea, the nurse would first check to ensure that the NG tube is functioning correctly, because the client’s nausea may be related to a blockage of the NG tube. If the tube is clogged, it can be irrigated with normal saline. An antiemetic may be given, but only after the nurse has determined that the NG tube is functioning properly. Postoperative prescriptions usually include an antiemetic. Typically, the nurse would notify the surgeon if the client did not obtain relief from irrigation of the NG tube or administration of a prescribed antiemetic. Although taking the client’s blood pressure is an important postoperative nursing activity, it is unrelated to relieving the client’s nausea.
When developing the postoperative plan of care for an adolescent who has undergone an appendectomy for a ruptured appendix, in which of the following positions should the nurse expect to place the client during the early postoperative period?
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Correct answer: D. The semi-Fowler’s position.
After an appendectomy for a ruptured appendix, assuming the semi-Fowler’s or a right side-lying position helps localize the infection. These positions promote drainage from the peritoneal cavity and decrease the incidence of subdiaphragmatic abscess.
Which of the following is a normal response from an adolescent who has just returned to her room after an appendectomy?
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Correct answer: B. "I’m worried about the size of my scar."
Adolescents are concerned about the immediate state and functioning of their bodies. The adolescent needs to know whether any changes (eg, illness, trauma, surgery) will alter her lifestyle or interfere with her quest for physical perfection. Having a scar may be devastating to the adolescent. The need for plastic surgery cannot be determined at this point. The adolescent has just returned from surgery and has yet to see the scar. Healing has yet to occur. Typically scars become smaller and fade over time. The desire for no pain is unrealistic. Although adolescents are worried about pain and how they will respond, they typically are discharged within 24 hours after an appendectomy with pain well controlled by oral analgesics. The immediate concern of adolescents is the state and functioning of their bodies. After concerns about themselves, then adolescents are concerned about their peer group and their responses. Although the boyfriend’s response will matter, this concern would be more common later in the course of the adolescent’s recovery.
Which of the following client actions should the nurse judge to be a healthy coping behavior for a male adolescent after an appendectomy?
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Correct answer: B. Insisting on wearing a T-shirt and gym shorts rather than pajamas.
Adolescents struggle for independence and identity, needing to feel in control of situations and to conform to peers. Control and conformity are often manifested in appearance, including clothing, and this carries over into the hospital experience. The adolescent feels best when he is able to look and act as he normally does, for example, wearing a T-shirt and gym shorts. Adolescents normally want to interact with peers and commonly seek every opportunity to do so. Avoiding other adolescents on the nursing unit or not taking phone calls from friends might suggest ineffective coping behavior. Refusing to fill out the menu and allowing the nurse to do so demonstrate dependent behavior, not a healthy coping mechanism
The nurse prepares to teach an adolescent scheduled for an appendectomy about what to expect. The adolescent says, "I would rather look this up on the Internet." The nurse should:
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Correct answer: A. Help the client find information on the Internet.
Part of providing client-centered care is to honor the client’s preferred method of learning. The nurse should help the adolescent find accurate information about the procedure. By assisting with the information search the nurse can verify learning. Teaching straight from a checklist does not encourage customization. If the client has requested to use the Internet, it is unlikely that written information will be read. While it is true that some information on the Internet is not accurate, the nurse can take this opportunity to help the client learn how to determine if a source is reliable.
The health care team wishes to establish a policy regarding sleep positions for infants with gastroesophageal reflux (GER). The first step should be to search for:
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Correct answer: B. Published national standards.
Published national standards are based on the best evidence and when available should serve as the foundation for nursing unit policies. Policies from other hospitals may or may not be evidence based. Retrospective studies and expert opinions should only be used to form policy when data from experimental studies or national standards are not available.
The nurse is assisting another member of the health care team who is placing a peripherally inserted catheter in a 10-year-old with peritonitis from a ruptured appendix. The family is present in the treatment room to support the child. The nurse observes that the other team member has contaminated a sterile glove. The nurse should:
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Correct answer: B. Tell the team member the glove is contaminated.
It is the responsibility of all health care members to protect the client. The provider may honestly not have realized that the glove was contaminated. Therefore, the nurse needs to alert the provider to the situation. Waiting until after the procedure to address the problem puts the child at unnecessary risk for infection. Asking the parents to leave could invoke anxiety in both the child and the parents. Alerting the provider does not need to be confrontational. If done with a calm approach, the result is most likely to be gratitude instead of embarrassment.
The hospital is responding to a mass casualty disaster with adult and pediatric victims. After reallocating staff, the charge nurse on the pediatric floor should:
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Correct answer: D. Review the census for clients that are candidates for early discharge.
The charge nurse can anticipate needing beds for incoming victims. Any client who can go home should go home. Parents are a child’s primary care givers and should not be asked to leave. If computers were not affected by the disaster, charting in the electronic health record is safer. Some routine procedures are altered during a disaster, but clients who are unstable will still need frequent assessments; reducing vital sign frequency must be considered on a case-to-case basis.
Eight hours ago, an infant with Hirschsprung’s disease had surgery to create a colostomy. Which of the following findings should alert the nurse to notify the primary care provider immediately?
Show answer and rationale
Correct answer: B. A 3-cm increase in abdominal circumference.
Abdominal circumference is measured to monitor for abdominal distention. An increase of 3 cm in 8 hours would require notification of the primary care provider; it would indicate a substantial degree of abdominal distention, possibly from fluid or gas accumulation. Normally, after surgery, an infant experiences occasional periods of fussiness. However, as long as the infant is able to be quiet by himself or with the aid of a pacifier, the primary care provider does not need to be contacted. Absence of bowel sounds would be expected after surgery because of the effects of anesthesia. It takes approximately 48 hours for gastric motility to resume. Even if the infant displays evidence that he is hungry, fluids will not be offered until bowel sounds are heard, indicating a functioning gastrointestinal tract.
A father brings his 4-week-old son to the clinic for a checkup, stating that he believes his son’s testicle is missing. Which of the following explanations would be most appropriate?
Show answer and rationale
Correct answer: D. "Although the testes normally descend by 1 year of age, I can understand your concern."
Normally the testes descend by 1 year of age; failure to do so may indicate a problem with patency or a hormonal imbalance. By age 4 weeks, descent may not have occurred. However, telling the father that lack of descent is not a cause for worry is inappropriate and uncaring. Additionally, a statement such as this may be false reassurance. By acknowledging the father’s concern, the nurse indicates acceptance of his feelings. If the testes have not descended, then they will not be palpable in the scrotal sac. Surgery is not discussed until after a full assessment is completed.
While the nurse is examining the infant for presence of testes, the father paces around the room shaking his head. Which of the following would be the most appropriate response by the nurse?
Show answer and rationale
Correct answer: A. "You seem upset; please tell me how you’re feeling."
The nurse needs more information about the father’s perceptions and feelings before providing any information or taking action. Determining the exact nature of the father’s concern rather than making an assumption about it is essential. Therefore, the nurse should identify what is observed and ask the father how he is feeling. Telling the father that everything will be fine or not to worry is inappropriate and provides false reassurance. It also devalues the father’s concern. Later on, it may be appropriate for the father to talk to a parent of a child with the same problem for support.
When assessing an infant with an undescended testis, the nurse should be alert for which of the following?
Show answer and rationale
Correct answer: B. A bulging in the inguinal area.
When an anomaly is found in one system, such as the genitourinary system, that system requires a more focused assessment to reveal other conditions that also may be occurring. A bulging in the inguinal area may suggest an inguinal hernia. Also, hydrocele or an upper urinary tract anomaly may occur on the same side as the undescended testis. A neuromuscular problem, not a genitourinary problem such as undescended testes, would most likely be the cause of abnormal lower extremity reflexes. A history of frequent emesis may be caused by pyloric stenosis or viral gastroenteritis. Poor weight gain might suggest a metabolic or a feeding problem.
When explaining the plan of care to the parents of an infant with an undescended testis, the nurse should tell the parents about which of the following as a nonsurgical treatment method?
Show answer and rationale
Correct answer: D. A trial of human chorionic gonadotrophic hormone.
A trial of human chorionic gonadotrophin may be given to stimulate descent of the affected testis. A trial of adrenocorticotropic hormone will not cause the testis to descend. The cremasteric reflex results in the testis being drawn up, the opposite of the intended effect. Application of warmth, such as warm baths, although soothing and relaxing for the infant, would have little or no effect on stimulating the testis to descend.
When developing the preoperative teaching plan for a 14-month-old child with an undescended testis who is scheduled to have surgery, which of the following methods is appropriate?
Show answer and rationale
Correct answer: A. Explaining to the parents how the defect will be corrected.
Preoperative teaching would be directed at the parents, because the child is too young to understand the teaching. Telling the child that his penis and scrotum will be "fixed," telling the child he will not see incisions after surgery, and using a doll to illustrate the surgery are appropriate interventions for a preschool-age child.
When explaining to the parents of a child with a hydrocele about the possible cause of the condition, the nurse bases this explanation on the interpretation that a hydrocele is most likely the result of which condition?
Show answer and rationale
Correct answer: A. A patent processus vaginalis that results in the collection of fluid along the spermatic cord or tunica vaginalis of the testicle.
A hydrocele is a collection of fluid in the tunica vaginalis of the testicle or along the spermatic cord that results from a patent processus vaginalis. Failure of the upper part of the processus vaginalis to atrophy allows the accumulation of fluid in the testicle and the peritoneal cavity, causing an inguinal hernia.
During a clinic visit, the mother of an infant with hydrocele states that the infant’s scrotum is smaller now than when he was born. After teaching the mother about the infant’s condition, which of the following statements by the mother indicates that the teaching has been effective?
Show answer and rationale
Correct answer: D. "It seems like the fluid is being reabsorbed."
A hydrocele is a collection of fluid in the tunica vaginalis of the testicle or along the spermatic cord that results from a patent processus vaginalis. Because scrotal size is decreasing, the fluid is being absorbed. Elevation of the infant’s bottom, massage, or keeping the infant quiet or in an infant seat would have no effect in promoting fluid reabsorption in hydrocele.
Shortly after an infant is returned to his room following hydrocele repair, the infant’s mother tells the nurse that the child’s scrotum looks swollen and bruised. Which of the following responses by the nurse would be most appropriate?
Show answer and rationale
Correct answer: B. "This is normal after this type of surgery. Let’s look at it together just to be sure."
Some swelling and bruising are normal postoperatively. By assessing the area with the mother, the nurse is conveying acceptance of the mother’s concern. In addition, the nurse needs to inspect the area to determine if what the mother is describing is accurate. Doing so also provides an opportunity for teaching. Aspirin is not usually prescribed for children because of the link between aspirin and Reye’s syndrome. Acetaminophen is commonly administered for fever or pain relief. Asking the mother to wait in the child’s room ignores the mother’s concerns. There is no need to notify the doctor at this time.
The parents of a neonate with hypospadias and chordee wish to have him circumcised. Which of the following explanations should the nurse incorporate into the discussion with the parents concerning the recommendation to delay circumcision?
Show answer and rationale
Correct answer: C. The foreskin is used to repair the deformity surgically.
The condition in which the urethral opening is on the ventral side of the penis or below the glans penis is referred to as hypospadias. Chordee refers to a ventral curvature of the penis that results from a fibrous band of tissue that has replaced normal tissue. Circumcision is delayed because the foreskin, which is removed with a circumcision, often is used to reconstruct the urethra. The chordee is corrected when the hypospadias is repaired. Circumcision is performed at the same time. Urethral meatal stenosis, which can occur in circumcised infants, results from meatal ulceration, possibly leading to urinary obstruction. It is not associated with hypospadias or circumcision. The infant is not too small to have a circumcision, which is commonly performed on the first or the second day of life.
A 1-year-old child is scheduled for surgery to correct hypospadias and chordee. The nurse explains to the parents that this is the preferred time for surgical repair based on which of the following?
Show answer and rationale
Correct answer: C. The child is too young to have developed castration anxiety.
The preferred time for surgery is between the ages of 6 and 18 months, before the child develops castration and body image anxiety. Children learn early on about society’s emphasis on the importance of genitals. Pain is different for each child and is not related to the preferred time for repair of the hypospadias or chordee. Although the child will probably not remember the experience, this is not the basis for having the surgery at this age. If the condition is not repaired, the child will have difficulty with toilet training because urine is not eliminated through the tip of the penis.
A 6-month-old child is discharged with a urinary stent after a procedure to repair a hypospadias. The nurse should tell the parents to:
Show answer and rationale
Correct answer: B. Avoid tub baths until the stent is removed.
The parents should keep the penis as dry as possible until the stent is removed. Soaking in a tub bath is not recommended. Children this age typically go home voiding directly into a diaper. Infants may be started on juice at 6 months of age. Parents are advised to keep their child well hydrated after a hypospadius repair. Therefore, there is no reason to avoid juice. Cleaning the tip of the penis three times a day may cause unnecessary irritation.
After teaching the parents about the urethral catheter placed after surgical repair of their son’s hypospadias, the nurse determines that the teaching was successful when the mother states that the catheter in her child’s penis accomplishes which of the following?
Show answer and rationale
Correct answer: A. Keeps the new urethra from closing.
The main purpose of the urethral catheter is to maintain patency of the reconstructed urethra. The catheter prevents the new tissue inside the urethra from healing on itself. However, the urethral catheter can cause bladder spasms. Recently, stents have been used instead of catheters. The urethral catheter will have no effect on the child’s pain level. In fact, because bladder spasms are associated with its use, the child’s problems of pain may actually increase. Urine output can be measured through the suprapubic catheter because it provides an alternative route for urinary elimination, thus keeping the bladder empty and pressure-free.
While assessing the penis of a child who has had surgery for repair of a hypospadias, the nurse observes the appearance of the penis. The nurse should report which aspect to the surgeon?
Show answer and rationale
Correct answer: C. Dusky blue at the tip.
A dusky blue color at the tip of the penis may indicate a problem with circulation, and the nurse should notify the surgeon. Following surgery, it is normal for the penis to be swollen and pink. The penis may be misshapen and is unlikely to look normal even after reconstruction.
When developing the teaching plan for the parents of a 12-month-old infant with hypospadias and chordee repair, which of the following should the nurse expect to include as most important?
Show answer and rationale
Correct answer: A. Preventing the child from disrupting the catheters by using soft restraints.
The most important consideration for a successful outcome of this surgery is maintenance of the catheters or stents. A 12-month-old infant likes to explore his environment but must be prevented from manipulating his dressings or catheters through the use of soft restraints. Allowing the infant to become familiar with the dressings will not prevent him from pulling at them. After surgery the child is allowed limited activity, possibly with sitting in the parent’s lap. A 12-month-old infant may or may not be walking. If he is, most likely he will be clumsy and possibly injure himself. Although increasing fluids is important, 2,500?mL/day is an excessive amount for a 12-month-old. Fluid requirements would be 115?mL/kg.
The physician prescribes a urinalysis for a child who has undergone surgical repair of a hypospadias. Which of the following results should the nurse report to the physician?
Show answer and rationale
Correct answer: C. Twenty-five white blood cells per high-powered field.
A normal white blood cell count in a urinalysis is 1 to 2 cells/mL. A white blood cell count of 25 per high-powered field indicates a urinary tract infection. A urine specific gravity of 1.017 is within the normal range of 1.002 to 1.030. After urologic surgery, it is not unusual for a small number of red blood cells to appear in the urine. The child’s urine pH is within the normal range of 4.6 to 8.
A 4-year-old with a history of urinary reflux returned from surgery for bilateral urethral reimplants 2 days ago. Which assessment finding is most concerning?
Show answer and rationale
Correct answer: C. Continuous drainage from a Foley catheter.
Children with bilateral ureteral implants often have pain with urination due to bladder spasms. Some children will avoid drinking in order to avoid the pain associated with urination, thus putting the child at risk for dehydration. Intermittent bladder spasms are common after ureteral reimplant surgery and can be treated with Ditropan (oxybutynin) to decrease discomfort. Small amounts of blood tinged urine, bladder spasms, urinary frequency, and urinary incontinence are common following ureteral reimplant surgery.
The health care provider has prescribed a sterile urine specimen on a 3-year-old boy with a history of recurrent urinary tract infections. The family is upset because the last time the child was catheterized the procedure was very painful and traumatic. The nurse should tell the family:
Show answer and rationale
Correct answer: B. "I will get a prescription for a lidocaine-based lubricant to make the procedure more comfortable."
Two percent lidocaine lubricants have been found to significantly reduce the pain of urinary catheter insertion in children. If the unit does not have a standing protocol to use the lubricant, the nurse should request a prescription. A sedative would carry with it additional risks that could be avoided with the use of other methods to reduce pain. The parents should be encouraged to hold the child in addition to other pain relief methods. Frequent urination would make the use of topical anesthetics that must be left in place for a period of time impractical.
The parents of a child on sulfamethoxazole and trimethoprim for a urinary tract infection report that the child has a red, blistery rash. The nurse should tell the parents to:
Show answer and rationale
Correct answer: C. Discontinue the medicine and come for immediate further evaluation.
Sulfonamides have been associated with severe adverse reactions. A blistering rash may be a sign of Stevens-Johnson syndrome, a severe allergic reaction that manifests as skin lesions. This reaction is life threatening and requires immediate attention. Lotion should not be applied to skin with blisters. Sulfamethoxazole and trimethoprim may cause photosensitivity, but this usually appears as a mild red rash, not blisters. Increasing the child’s fluid intake may help the urinary tract infection, but does not address the rash.
A recent history of which of the following should alert the nurse to gather additional information about the possibility of a urinary tract infection in a 2-year-old child who is exhibiting fever and fussiness?
Show answer and rationale
Correct answer: D. Abdominal pain.
Abdominal pain frequently accompanies urinary tract infection in children 2 years of age and older. Other associated signs and symptoms include decreased appetite, vomiting, fever, and irritability. The presence of swollen lymph glands (lymphadenopathy) is unrelated to urinary tract infections. Lymphadenopathy is associated with a systemic infection or possibly cancer. Skin rash is associated with exposure to allergens or irritants (eg, poison ivy or harsh soaps); prolonged contact with urine (eg, diaper dermatitis); or illnesses such as measles, rheumatic fever, or juvenile rheumatoid arthritis. Flank or back pain is associated with urinary tract infection in children older than 2 years of age and in adults.
A father of a child with a urinary tract infection calls the clinic and explains, "My wife and I are concerned because our child refuses to obey us concerning the preventions you told us about. Our child refuses to take the medication unless we buy a present. We don’t want to use discipline because of the illness, but we’re worried about the behavior." Which response by the nurse is best?
Show answer and rationale
Correct answer: C. "I understand it’s hard to discipline a child who is ill, but things need to be kept as normal as possible."
To ensure appropriate psychosocial development, a child needs to have normal patterns maintained as much as possible during illness. It is tempting to give ill children special treatment and to relax discipline. However, family routines and discipline should be kept as normal as possible. The child needs to know the limits to ensure feelings of security. When they are ill, children commonly attempt to stretch the rules and limits. If this occurs, returning to the previous well-behavior patterns will take time.
A 15-year-old has been diagnosed with acute glomerulonephritis and has been in the hospital for 1 day. Which of the following findings requires immediate action?
Show answer and rationale
Correct answer: D. Urine specific gravity of 1.030.
An adolescent with acute glomerulonephritis has a high urine specific gravity related to oliguria caused by inflammation of the glomeruli. The client will have periorbital edema, but not the generalized edema that occurs in nephrotic syndrome. In glomerulonephritis, there is some albumin in the urine, but there are large amounts of red blood cells, giving the urine a brown color. The urine in glomerulonephritis is scanty, averaging about 400?mL in 24 hours, which leads to fluid volume excess and hypertension.
Which of the following meals would be most appropriate for a 15-year-old with glomerulonephritis with severe hypertension?
Show answer and rationale
Correct answer: C. Baked chicken, rice, beans, orange juice.
The best selection of food would include no added salt or salty food. Because sodium cannot be excreted due to the oliguria and to avoid increasing the hypertension, a low-salt diet is recommended. Most canned foods have sodium added as a preservative. Hamburger, ham, hot dogs, canned peas, canned carrots, corn chips, pickles, and milk are high in sodium.
A 10-year-old with glomerulonephritis reports a headache and blurred vision. The nurse should immediately:
Show answer and rationale
Correct answer: B. Obtain the child’s blood pressure.
Hypertension occurs with acute glomerulonephritis. The symptoms of headache and blurred vision may indicate an elevated blood pressure. Hypertension in acute glomerulonephritis occurs due to the inability of the kidneys to remove fluid and sodium; the fluid is reabsorbed, causing fluid volume excess. The nurse must verify that these symptoms are due to hypertension. Calling the physician before confirming the cause of the symptoms would not assist the physician in his treatment. Putting the client to bed may help treat an elevated blood pressure, but first the nurse must establish that high blood pressure is the cause of the symptoms. Administering Tylenol for high blood pressure is not recommended.
Which of the following questions should the nurse ask first when obtaining a history from the mother of a 10-year-old child with a fever, malaise, and swelling around the eyes?
Show answer and rationale
Correct answer: D. "Does the child urinate as much as usual?"
Most likely, the nurse suspects that the child is exhibiting signs and symptoms of glomerulonephritis, such as periorbital edema and fever. Other signs and symptoms include loss of appetite, dark-colored urine, pallor, headaches, and abdominal pain. To confirm this suspicion, the nurse would ask about the child’s urinary elimination patterns. Typically the child with glomerulonephritis experiences a decrease in urine output. Asking about any recent sore throat would provide additional information to confirm the suspicion of glomerulonephritis, because the most common type is acute poststreptococcal glomerulonephritis, which follows a strep throat by 10 to 14 days. Frequently, the children have only mild cold symptoms and do not realize they have a streptococcal infection. Asking whether the child plays with friends as usual is important and gives the nurse information about how the child feels in general. However, this is a general question that would be appropriate to ask later on in the history. Although asking the mother about the color of the child’s urine is important, the nurse needs to determine whether there is any change in the child’s urinary output first.
A school-age client admitted to the hospital because of decreased urine output and periorbital edema is diagnosed with acute poststreptococcal glomerulonephritis. Which of the following actions should receive the highest priority?
Show answer and rationale
Correct answer: C. Obtaining daily weight measurements.
The child with acute poststreptococcal glomerulonephritis experiences a problem with renal function that ultimately affects fluid balance. Because weight is the best indicator of fluid balance, obtaining daily weights would be the highest priority.
When developing the plan of care for a school-age child with acute poststreptococcal glomerulonephritis who has a fluid restriction of 1,000?mL/day, which of the following fluids should the nurse consider as most appropriate for the client’s condition and effective for preventing excessive thirst?
Show answer and rationale
Correct answer: A. Ice chips.
The most appropriate and effective choice would be ice chips, because they help moisten the mouth and lips while keeping fluid intake low. However, ice chips must still be counted as intake with the fluid restriction. Sweet beverages, such as diet cola or lemonade, commonly increase thirst. Tap water effectively relieves thirst but does not help keep fluid intake low.
The nurse is planning interventions for a school-aged child in need of diversional activity. Which of the following activities should the nurse expect to include?
Show answer and rationale
Correct answer: D. Playing a card game with someone the same age.
Generally, school-age children enjoy activities with their peers first, then family members, and lastly younger children. School-age children like to be busy but also to accomplish something. This helps to meet their task of industry versus inferiority, feeling good about what they are able to accomplish.
A 10-year-old child hospitalized with acute poststreptococcal glomerulonephritis during the acute stage has elevated blood pressure and low urine output for 14 hours. The nurse should next:
Show answer and rationale
Correct answer: D. Assess the child’s neurologic status.
The nurse should assess the child’s neurologic status, because hypertensive encephalopathy is a major potential complication of the acute phase of glomerulonephritis. Seizure precautions also should be instituted. Hypertensive encephalopathy can result in transient loss of vision, hemiparesis, disorientation, and grand mal seizures. Encouraging the child to drink more water is inappropriate because the child has had a low urine output for 14 hours. Typically, in this situation, fluids would be restricted. Although a low-sodium diet is encouraged, it is not the priority action at this time. Initially, bed rest, not ambulation, is advocated during the acute phase of glomerulonephritis.
When developing the discharge plan for a school-age child diagnosed with acute poststreptococcal glomerulonephritis, which instruction should the nurse plan to discuss?
Show answer and rationale
Correct answer: B. Preventing respiratory infections.
Children recovering from glomerulonephritis need to avoid exposure to all types of infections. Glomerulonephritis is caused by group A beta-hemolytic streptococcus, a common cause of sore throat. As the child recovers, he or she may be susceptible to a recurrence if exposed to the organism again. During convalescence from glomerulonephritis, fluid and dietary restrictions are no longer indicated because the kidneys are now functioning normally. There is no need for the parents to assess the child’s vital signs.
A parent of a child with acute poststreptococcal glomerularnephritis (APSGN) asks how a strep infection caused their child to have a kidney problem. What is the nurse’s best response?
Show answer and rationale
Correct answer: C. "By-products of immune complexes that fought the infection are depositing in the kidneys."
APSGN is an immune complex disease. Large antigen-antibody complexes are formed that deposit in the glomerular capillary loops leading to obstruction. APSGN is considered an autoimmune disorder, not an infection. Antibodies do not attack the kidneys in this disorder.
A child with nephrosis is taking prednisone. The nurse should teach the caregivers to report which of the following adverse effects?
Show answer and rationale
Correct answer: D. Both of the above
Adverse effects of steroid therapy include edema of the face and trunk, increased susceptibility to infection, gastric and intestinal mucosal bleeding, sodium and water retention, and hypertension. Urinary output is decreased due to the retention of sodium. Bleeding gums do not result from steroids. Steroid therapy does not cause vision problems.
The nurse determines that the blood pressure represents a change and notifies the primary care provider of the assessment of:
Show answer and rationale
Correct answer: A. Hypertension.
Reading at or above the 95th percentile are considered indicative of hypertension. Here, both the systolic and diastolic readings are at the 95th percentile for a boy who is at the 75th percentile for height. This blood pressure may be a side effect of the medication or part of the disease process and needs to be reported. The charts do not define hypotension. Readings below the 90th percentile are considered normal. Blood pressures at the 90th percentile, but below the 95th are considered prehypertension. Blood pressures at the 99th percentile are considered stage II hypertension and are most likely to need antihypertensive medications.
Which of the following statements by the mother of a toddler diagnosed with nephrotic syndrome indicates that the mother has understood the nurse’s teaching about this disease?
Show answer and rationale
Correct answer: B. "My child really likes chips and bologna. I guess we’ll have to find something else."
Children with nephrotic syndrome usually require sodium restriction. Because potato chips and bologna are high in sodium, the mother’s statement about finding something else reflects understanding of this need. Although fluid intake is not restricted in children with nephrotic syndrome, 4 L is an excessive amount for a toddler. The typical fluid requirement for a toddler is 115?mL/kg. Surgical intervention and antibiotic therapy are not parts of the treatment plan for nephrotic syndrome.
A toddler diagnosed with nephrotic syndrome has a fluid volume excess related to fluid accumulation in the tissues. Which measure should the nurse anticipate including in the child’s plan of care?
Show answer and rationale
Correct answer: A. Weighing the child before breakfast.
The best indicator of fluid balance is weight. Therefore, daily weight measurements help determine fluid losses and gains. Although limiting visitors to 2 to 3 hours per day or maintaining strict bed rest would help to ensure that the child gets adequate rest, this is unrelated to the child’s fluid balance. In nephrotic syndrome, urine is tested for protein, not specific gravity.
The mother of a toddler with nephrotic syndrome asks the nurse what can be done about the child’s swollen eyes. Which measure should the nurse suggest?
Show answer and rationale
Correct answer: C. Elevating the head of the child’s bed.
The child’s swollen eyes are caused by fluid accumulation. Elevating the head of the bed allows gravity to increase the downward flow of fluids in the body, away from the face. Applying cool compresses or eye drops, or limiting television, may be comforting but will not relieve the swelling.
The nurse determines that interventions for decreasing fluid retention have been effective when the child with nephrotic syndrome demonstrates evidence of which of the following?
Show answer and rationale
Correct answer: C. Decreased abdominal girth.
Fluid accumulates in the abdomen and interstitial spaces owing to hydrostatic pressure changes. Increased abdominal fluid is evidenced by an increase in abdominal girth. Therefore, decreased abdominal girth is a sign of reduced fluid in the third spaces and tissues. When fluid accumulates in the abdomen and interstitial spaces, the child does not feel hungry and does not eat well. Although increased caloric intake may indicate decreased intestinal edema, it is not the best and most accurate indicator of fluid retention. Increased respiratory rate may be an indication of increasing fluid in the abdomen (ascites) causing pressure on the diaphragm. Heart rate usually stays in the normal range even with excessive fluid volume.
The toddler with nephrotic syndrome exhibits generalized edema. Which of the following measures should the nurse institute for this child with impaired skin integrity related to edema?
Show answer and rationale
Correct answer: B. Separate opposing skin surfaces with soft cloth.
Placing soft cloth between opposing skin surfaces absorbs moisture and keeps the area dry, thus preventing any further breakdown. The child with nephrotic syndrome and severe edema is usually maintained on bed rest. Therefore, ambulation is not appropriate. Applying lotion or powder to edematous surfaces that touch increases moisture and can lead to maceration, causing further breakdown.
The nurse is planning care with the parents of a child who requires continuous peritoneal dialysis. Which finding should be discussed with the physician?
Show answer and rationale
Correct answer: C. The child reports having a previous surgery for a ruptured appendix.
A client who has had a ruptured appendix may have peritoneal scarring that may alter the effectiveness of treatment. Living a long distance from a medical facility is typically a reason to select peritoneal dialysis. Attending a large school is not a problem, but the school nurse needs to be included as part of the health care team. Typically the treatment schedule can be planned to allow for uninterrupted sleep at night.
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?
Show answer and rationale
Correct answer: A. Examining the site for signs of infection while cleaning the area.
Until it heals, the catheter exit site is particularly vulnerable to invasion by pathogenic organisms. Therefore, the site must be monitored for signs of infection. An occlusive dressing is not needed because there is no danger of air being sucked in or out of the peritoneal space. Furthermore, the catheter used is designed with a cuff, so that the skin grows around the catheter, sealing off the area. Site care may be done at any time, but the child may experience abdominal discomfort if the peritoneal space is dry during site care. Holding the catheter taut or pulling on it may cause irritation of the skin at the exit site, which could lead to infection.
When a client is diagnosed with aplastic anemia, the nurse should assess the client for changes in which of the following physiologic functions?
Show answer and rationale
Correct answer: B. Bleeding tendencies.
Aplastic anemia decreases the bone marrow production of red blood cells (RBCs), white blood cells, and platelets. The client is at risk for bruising and bleeding tendencies. A change in the client’s intake and output is important, but assessment for the potential for bleeding takes priority. Change in the peripheral nervous system is a priority problem specific to clients with vitamin B12 deficiency. Change in bowel function is not associated with aplastic anemia.
Which of the following diet plans would be appropriate for the nurse to discuss with the family of a child with acute renal failure?
Show answer and rationale
Correct answer: D. High fat and carbohydrate.
The child with acute renal failure needs extra calories to reduce tissue catabolism, metabolic acidosis, and uremia. Using a high-fat and carbohydrate diet helps to supply the necessary extra calories. If the child is able to tolerate oral foods, concentrated food sources that are high in carbohydrate and fat but low in protein, potassium, and sodium may be provided.
Possible effect on body image of the presence of an abdominal catheter.
Show answer and rationale
Correct answer: C. Tissue swelling.
Tissue swelling, pain, redness, and exudate indicate infection. Dialysate leakage is associated with improper catheter function, incomplete healing at the insertion site, or excessive instillation of dialysate. Granulation tissue indicates healing around the exit site, not infection. Increased time for drainage may indicate that the tube is kinked, suggesting an obstruction.
After teaching the mother of a young child with a peritoneal catheter about the signs and symptoms of peritonitis, the nurse determines that the mother has understood the teaching when she identifies which of the following as an important sign?
Show answer and rationale
Correct answer: B. Cloudy dialysate drainage return.
Normally, dialysate drainage return should be clear. With peritonitis, large numbers of bacteria, white blood cells, and fibrin cause the dialysate to appear cloudy. Abdominal distention is unrelated to peritonitis. However, it might suggest an obstruction. Weight gain and shortness of breath are associated with fluid excess, not infection.
The nurse assesses the child with chronic renal failure who is receiving peritoneal dialysis for edema. Which finding is expected for this child?
Show answer and rationale
Correct answer: A. Pallor.
With edema, pallor can occur owing to hemodilution as intestinal fluid moves to the vascular space. The child would exhibit pulmonary crackles secondary to pulmonary congestion and edema. Dialysate outflow would decrease, not increase, as the body attempts to conserve fluid. The child’s blood pressure would be increased because of excessive fluid volume.
A client is afraid of receiving vitamin B12 injections because of potential toxic reactions. Which is the nurse’s best response to relieve these fears?
Show answer and rationale
Correct answer: B. "Vitamin B12 is generally free of toxicity because it is water soluble."
Vitamin B12 is a water-soluble vitamin. When water-soluble vitamins are taken in excess of the body’s needs, they are filtered through the kidneys and excreted. Vitamin B12 is considered to be nontoxic. Adverse reactions that have occurred are believed to be related to impurities or to the preservative in B12 preparations. Ringing in the ears, rash, and nausea are not considered to be related to vitamin B12 administration.
The nurse judges that the mother understands the diet restrictions for her child with chronic renal failure who is receiving peritoneal dialysis when she reports providing a diet involving which of the following?
Show answer and rationale
Correct answer: A. Protein and phosphorous restrictions.
Regulation of the diet is the most effective means, besides dialysis, for reducing renal excretion. Dietary phosphorus is restricted, which reduces the protein load on the kidneys. Clients are also given substances to bind phosphorus in the intestines to prevent absorption. Limited protein in the diet should include foods high in essential amino acids. Foods high in fat and carbohydrate are used to increase caloric intake. Sodium and water may not be restricted because of the continual loss of sodium and water through the dialysate. Iron-rich foods are commonly high in protein.
A client with microcytic anemia is having trouble selecting food from the hospital menu. Which food is best for the nurse to suggest for satisfying the client’s nutritional needs?
Show answer and rationale
Correct answer: A. Brown rice.
Brown rice is a source of iron from plant sources (nonheme iron). Other sources of nonheme iron are whole-grain cereals and breads, dark green vegetables, legumes, nuts, dried fruits (apricots, raisins, dates), oatmeal, and sweet potatoes. Egg yolks have iron but it is not as well absorbed as iron from other sources. Vegetables are a good source of vitamins that may facilitate iron absorption. Tea contains tannin, which combines with nonheme iron, preventing its absorption.
When assessing a 2-year-old child with Wilms’ tumor, the nurse should avoid?
Show answer and rationale
Correct answer: A. Palpating the child’s abdomen.
The abdomen of the child with Wilms’ tumor should not be palpated because of the danger of disseminating tumor cells. Techniques such as measuring the occipitofrontal circumference (which is done in children younger than 18 months of age because the anterior fontanel closes between 12 and 18 months of age), upright positioning, and measuring chest circumference are not necessarily contraindicated; however, the child with Wilms’ tumor should always be handled gently and carefully.
Which statement by the mother of a child with Wilms’ tumor tells the nurse that the mother understands what stage II tumor means?
Show answer and rationale
Correct answer: C. "The tumor has extended beyond the kidney but was completely removed."
A stage II tumor is one that extends beyond the kidney but is completely resected. The tumor staging is verified during surgery to maximize treatment protocols. The following criteria for staging are commonly used: stage I, tumor is limited to the kidney and completely resected; stage II, tumor extends beyond the kidney but is completely resected; stage?III, residual nonhematogenous tumor is confined to the abdomen; stage IV, hematogenous metastasis occurs, with deposits beyond stage III (lung, bone and brain, liver); stage V, bilateral renal involvement is present at diagnosis.
A client with macrocytic anemia has a burn on the foot and reports watching television while lying on a heating pad. Which action should be the nurse’s first response?
Show answer and rationale
Correct answer: B. Check for diminished sensations.
Macrocytic anemias can result from deficiencies in vitamin B12 or ascorbic acid. Only vitamin B12 deficiency causes diminished sensations of peripheral nerve endings. The nurse should assess for peripheral neuropathy and instruct the client in self-care activities for diminished sensation to heat and pain (eg, using a heating pad at a lower heat setting, making frequent checks to protect against skin trauma). The burn could be related to abuse, but this conclusion would require more supporting data. The findings should be documented, but the nurse would want to address the client’s sensations first. The decision of how to treat the burn should be determined by the physician.
After a child undergoes nephrectomy for a Wilms’ tumor, the nurse should assess the child postoperatively for which early sign of a complication?
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Correct answer: C. Increased abdominal distention.
Children who have undergone abdominal surgery are at risk for intestinal obstruction from a dynamic ileus. Indications of intestinal obstruction include abdominal distention, decreased or absent bowel sounds, and vomiting. Later signs of intestinal obstruction include tachycardia, fever, hypotension, increased respirations, shock, and decreased urinary output.
When developing the discharge plan for a child who had a nephrectomy for a Wilms’ tumor, the nurse identifies outcomes to prevent damage to the child’s remaining kidney and accomplish which of the following?
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Correct answer: C. Prevent urinary tract infection.
Because the child has only one kidney, measures should be recommended to prevent urinary tract infection and injury to the remaining kidney. Severe pain and dependent edema are not associated with surgery for Wilms’ tumor. Dietary sodium is not restricted because function in the remaining kidney is not impaired.
The charge nurse finds the mother of a child with a chronic bladder condition requiring clean intermittent catheterization (CIC) visibly upset. The mother states, "That other nurse said parents are not allowed to perform CIC in the hospital because of increased infection risk." The charge nurse should tell the parent:
Show answer and rationale
Correct answer: C. "You can use CIC on your child. I will talk with your nurse to clarify the policy."
The charge nurse should assure the parent that it is okay to use CIC and discuss the conversation with the nurse. It is possible that the nurse was unaware of current research findings or unit policies. The charge nurse should also determine if the parent has the supplies and uses a new catheter each time, but the insertion principles would not change. Parents are frequently taught how to do CIC while a child is in the hospital. Therefore, the rationale that it now becomes unsafe, or that sterile technique is needed, is faulty. Switching nurses will not solve the underlying problem.
The parent of an 18-year-old with chronic renal disease states, "My son has so many problems. I’m really worried that he will not get the right care if he gets sick at college." The nurse should tell the parent:
Show answer and rationale
Correct answer: C. "Your son can make an e-health history to facilitate his care if he gets sick away from home."
Access to a well-constructed e-history will facilitate care if the adolescent becomes ill while at college. Because the client is 18, legally the nurse cannot transfer the records to the school without permission. Also, the adolescent may need to seek treatment in facilities other than the health center. Instructing the adolescent to always carry the nephrologist’s phone number is not bad advice, but compliance may vary and there is no guarantee the provider will be available in all instances. Telling the parent that the son must learn to manage his own disease does not address the parent’s concern.
A 17-year-old female with severe nodular acne is considering treatment with isotretinoin (Accutane). Prior to beginning the medication, the nurse explains that the client will be required to:
Show answer and rationale
Correct answer: B. Enroll in a risk management plan.
Because of the risk of birth defects with isotretinoin, risk management plans require all clients to meet certain requirements to obtain the medication. Providers are advised to closely monitor clients for signs of depression, but a mental health evaluation is not universally required. Women of child-bearing age must use two forms of effective birth control for 2 months before, during, and 1 month after taking the drug. Isotretinoin may cause muscle aches and extreme exercise should be avoided, but general participation in sports should be considered on an individual basis.
What to do with your score
Score the set, then spend longer on the review than you did on the questions. For every item you missed, decide which of three things went wrong: you did not know the fact, you misread what the item was asking, or you knew the fact and still chose second-best. Those need three different fixes — content review, slower reading, and priority-framework practice — and lumping them together is why question banks stop working for people.
Read the rationale on the items you got right as well. Arriving at the correct option for the wrong reason is common, and it does not survive a harder version of the same question.
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