The client has a history of Wilms tumor with left radical nephrectomy diagnosed at age five for which he completed treatment nine months ago. A septic episode, while undergoing treatment for his Wilms tumor, resulted in an acute kidney injury. This Injury, along with antibiotic therapy and chemotherapy, has resulted in chronic kidney disease. The client is followed by oncology and nephrology services.

For each nursing action, click to indicate whether the action is indicated or contraindicated for this client's plan of care.

Each row must have only one response option selected.

Continuous pulse oximetry monitoring

Calculation of intake and output

Daily weights

IV 0.9% normal saline continuous infusion at 100 mL/hr

IV potassium sparing diuretic

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}

Continuous pulse oximetry monitoring is indicated for assessing oxygen saturation and respiratory status, especially in a client with a history of chronic kidney disease and a previous septic episode. It helps monitor the client's respiratory function.

Calculation of intake and output is indicated to assess fluid balance, which is crucial in clients with chronic kidney disease and a history of acute kidney injury. It helps monitor fluid management.

Daily weights are indicated to monitor fluid retention and changes in the client's weight, which can be affected by the client's kidney condition and the administration of intravenous fluids.

IV 0.9% normal saline continuous infusion at 100 mL/hr is indicated to maintain hydration and promote renal function in clients with chronic kidney disease. It helps ensure adequate fluid balance.

IV potassium-sparing diuretics may be contraindicated because they can potentially affect electrolyte balance, and in some cases, they might not be suitable for clients with chronic kidney disease. The use of diuretics should be carefully evaluated and managed by the healthcare provider.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A. Report the assessment to the healthcare provider.

The changing color of the inguinal hernia to dark purple is concerning and may indicate a possible strangulated hernia, which is a surgical emergency. Additionally, the absence of a bowel movement for 24 hours raises concerns about possible bowel obstruction or compromise. The FLACC score of 8 on the initial assessment suggests that the infant is experiencing significant discomfort or pain.

Therefore, the priority is to report the assessment findings to the healthcare provider to ensure timely evaluation and intervention. The healthcare provider needs to assess the hernia, determine if it is strangulated, and decide on the appropriate course of action, which may include surgery. It is essential to act promptly in this situation to prevent potential complications.

B. Determining when oral fluids were last taken is relevant but should not take precedence over the potential surgical emergency of a strangulated hernia.

C. Attempting to reduce the hernia manually is not advisable in this situation, as it may worsen the condition if the hernia is strangulated.

D. Preparing to initiate venous access for an intravenous (IV) infusion is a consideration but should follow the assessment and reporting of the potential surgical emergency. Intravenous access may be needed as part of the overall management, but the priority is to ensure the infant receives appropriate surgical evaluation and intervention.

A. Report the assessment to the healthcare provider.

B. Determining when oral fluids were last taken is relevant but should not take precedence over the potential surgical emergency of a strangulated hernia.

C. Attempting to reduce the hernia manually is not advisable in this situation, as it may worsen the condition if the hernia is strangulated.

A. Document the client's relief of pain. B. Inquire about the client's last meal. C. Give prescribed intravenous antibiotics. D. Contact the healthcare provider.

Correct Answer is D

Explanation

A. Documenting the client's relief of pain is important for the medical record but is not the first priority in this situation. The immediate concern is to determine the cause of the sudden pain relief and ensure the child's well-being.

B. Inquiring about the client's last meal is important for pre-operative considerations, but it is not the first action to take when sudden relief of abdominal pain is reported.

C. Giving prescribed intravenous antibiotics may be part of the treatment plan, but it should not be the first action when the child experiences sudden relief of abdominal pain. Contacting the healthcare provider to assess the situation is more urgent.

D Contact the healthcare provider.

In the case of a child diagnosed with appendicitis, sudden relief in abdominal pain can be concerning. This might indicate that the appendix has ruptured, leading to the spread of infection into the abdominal cavity, which can be a critical situation. It's essential for the healthcare provider to be informed immediately so they can assess the child's condition, order any necessary interventions, and potentially expedite the surgical procedure if required.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A 9-year-old admitted to the unit with severe abdominal pain and fever is diagnosed with appendicitis and is placed on the surgery schedule for an appendectomy. The child reports to the nurse of experiencing sudden relief in abdominal pain. Which action should the nurse take first?

Correct Answer is D

Explanation

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