The nurse is reviewing the history and physical notes, as well as the nurse’s notes and laboratory results for a child.
The child is developmentally appropriate, interacting with his parents, and is in the percentile for weight and height.
The child’s lung sounds are clear and equal, a murmur is noted upon auscultation, and clubbing of the fingers is observed.
There is no skin breakdown, and the mucous membranes are pink and moist.
What condition is the child most likely experiencing, what two actions should the nurse take for this condition, and what two parameters should the nurse monitor to assess the child’s progress?
Polycythemia.
Temperature.
The Correct Answer is A
Choice A rationale
The child’s symptoms, including clear and equal lung sounds, a murmur upon auscultation, and clubbing of the fingers, suggest a condition affecting the heart and lungs. Polycythemia, a condition characterized by an increased number of red blood cells, could explain these symptoms. The nurse should monitor the child’s hematocrit and hemoglobin levels, as these can be elevated in polycythemia. The nurse should also monitor the child’s oxygen saturation, as hypoxia can occur in polycythemia3.
Choice B rationale
While temperature is an important vital sign to monitor in any patient, it does not directly address the child’s symptoms or the likely underlying condition. Therefore, it is not the most relevant choice in this scenario3. Diabetic ketoacidosisDiabetic ketoacidosis Explore
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While altered taste sensation can occur with radiation treatment, it’s not the most likely reason for an imbalance in nutritional intake in this scenario.
Choice B rationale
Fatigue can be a side effect of radiation treatment, but it’s not the primary reason for an imbalance in nutritional intake in this case.
Choice C rationale
Pain during eating is the most likely cause of imbalanced nutritional intake in this scenario. The patient’s laryngeal cancer and the development of mucositis indicate that eating is likely painful for them. This discomfort can significantly deter the patient from eating, leading to decreased nutritional intake.
Choice D rationale
Nausea can occur with radiation treatment, but it’s not the primary reason for an imbalance in nutritional intake in this case.
Correct Answer is B
Explanation
Choice A rationale
Encouraging the client to drink at least 3 to 4 liters of water prior to the procedure is not a standard preparation for an intravenous pyelogram (IVP). Overhydration could potentially complicate the procedure.
Choice B rationale
It is essential for the nurse to notify the healthcare provider if the client reports any allergies to iodine or shellfish. The contrast dye used in an IVP often contains iodine. People who are allergic to iodine or shellfish may have a reaction to this dye.
Choice C rationale
Instructing the client to keep the legs straight for 6 to 8 hours after the procedure is not a standard instruction for IVP. This instruction is more commonly associated with procedures involving the insertion of a catheter into a large artery or vein.
Choice D rationale
Inserting an indwelling urinary catheter prior to going to the X-ray department is not a standard preparation for an IVP. The procedure involves the injection of a contrast dye into a vein, not the bladder.
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