The nurse is providing care for a 10-month-old infant diagnosed with a Wilms tumor. Most parents report feeling a mass when:
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Solution
Answer A is correct. A Wilms tumor is found by most parents when the infant is being diapered or bathed. Answers B, C, and D are not associated with a Wilms tumor; therefore, they are incorrect.
The nurse is caring for an infant with atopic dermatitis. An important part of the infant’s care will be:
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Solution
Answer B is correct. The infant’s fingernails should be kept short to prevent scratching the skin. Keeping the infant warm will increase itching; therefore, answer A is incorrect. Soap should not be used because it dries the skin; therefore, answer C is incorrect. Peroxide is damaging to the tissues; therefore, answer D is incorrect.
The nurse is administering Pyridium (phenazopyridine) to a client with cystitis. The nurse should tell the client that:
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Solution
Answer C is correct. The medication will cause the urine to become red-orange in color. Answers A, B, and D are not associated with the use of Pyridium; therefore, they are incorrect.
A 3-year-old is diagnosed with diarrhea caused by an infection with salmonella. Which of the following most likely contributed to the child’s illness?
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Solution
Answer B is correct. Salmonella infection is commonly associated with turtles. Answers A, C, and D are incorrect because they are not sources of salmonella infection.
A client hospitalized with renal calculi complains of severe pain in the right flank. In addition to complaints of pain, the nurse can expect to see changes in the client’s vital signs, which include:
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Solution
Answer B is correct. The client in pain usually has an increased blood pressure. Answers A and C are incorrect because the client in pain will have an increase in the pulse rate and respirations. Temperature is not affected by pain; therefore, answer D is incorrect.
The physician has prescribed Gantrisin (sulfasoxazole) 1 gram in divided doses for a client with a urinary tract infection. The nurse should administer the medication:
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Solution
Answer B is correct. Gantrisin and other sulfa drugs should be given 30 minutes before meals to enhance absorption. Answer A is incorrect because the medication should be given before eating. Answer C is incorrect because the medication should be given on an empty stomach. Answer D is incorrect because the medication is to be given in divided doses throughout the day.
While performing a neurological assessment on a client with a closed head injury, the licensed practical nurse notes a positive Babinski reflex. The nurse should:
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Solution
Answer D is correct. A positive Babinski reflex in adults should be reported to the charge nurse because it indicates an abnormal finding. Answer A is incorrect because a positive Babinski sign in the adult is abnormal, therefore it does not indicate that the client’s condition is improving. Answer B is incorrect because changing the position will not alter the finding. Answer C is incorrect because a positive Babinski reflex is an expected finding in the infant but not in adults.
The nurse is preparing to walk the post-operative client for the first time since surgery. Before walking the client, the nurse should:
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Solution
Answer B is correct. Before walking the client for the first time since surgery, the nurse should ask the client to sit on the side of the bed and dangle his legs, to prevent postural hypotension. Pain medication should not be given before walking; therefore, answer A is incorrect. Answers C and D have no relationship to walking the client; therefore, they are incorrect.
A client has a diagnosis of discoid lupus. The primary difference in discoid lupus and systemic lupus is that discoid lupus:
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Solution
Answer B is correct. Discoid lupus is confined to the skin, producing “coinlike” lesions on the skin. Answers A, C, and D refer to systemic lupus; therefore, they are incorrect.
The nurse is caring for a 3-year-old in a wet hip spica cast made from plaster of Paris. When turning the 3-year-old with a wet cast, the nurse should:
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Solution
Answer C is correct. The nurse should handle the cast using the palms of the hands, to prevent indentations in the cast. Answer A is incorrect because grasping the cast with the hands will produce indentations that cause pressure points. Answers B and D are incorrect choices because assistive slings and lifting devices would frighten the 3-year-old and are not needed.