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.

Answer and Explanation

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

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Free Nursing Study Resources

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

Explanation

Based on the provided information, here are the interventions the nurse should perform:

Check capillary refill on bilateral upper extremities.- Indicated: This is important to assess the client’s circulation, especially given the coolness of the left arm and the fracture in the left shoulder.
Administer ondansetron 4 mg IV.- Contraindicated: There is no prescription for ondansetron and no indication of nausea or vomiting from the client.
Inspect the bandage for drainage.- Indicated: Given the client’s recent surgery and the presence of swelling and bruising, it’s important to monitor for any signs of infection or complications.

A. A client with a positive Mantoux and sputum cultures results positive for acid-fast bacillus (AFB). B. An older client with scabies who is admitted from an extended care facility. C. Twin siblings admitted with scarlet fever that is complicated with pneumonia. D. A female adolescent admitted with multiple genital Herpes simplex II lesions.

Correct Answer is A

Explanation

Choice A rationale

A client with a positive Mantoux test and sputum cultures positive for acid-fast bacillus (AFB) is indicative of tuberculosis, an airborne disease. This client would require a room with negative airflow, use of a particulate respirator mask, and adherence to airborne as well as standard precautions.

Choice B rationale

Scabies is a skin infestation caused by a mite. It is transmitted through direct skin-to-skin contact and does not require airborne precautions.

Choice C rationale

Scarlet fever is a bacterial illness that often presents with a rash and is associated with strep throat. It is spread by direct contact with mucus, saliva, or skin sores of a person infected with the bacteria. It does not require airborne precautions.

Choice D rationale

Herpes simplex II lesions are typically sexually transmitted and do not require airborne precautions. Standard precautions would be sufficient.

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Naxlex Comprehensive Predictor Exams

Exhibits Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

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

Explanation

The nurse is working on an infectious disease unit.Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

Correct Answer is A

Explanation

A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair.Which intervention is most important for the nurse to include in the plan of care?

A nurse is assessing a 3-month-old patient who underwent a pyloromyotomy the previous day.Which of the following findings would indicate a need for pain medication? Select all that apply.

A healthcare provider prescribes a low-fiber diet for a patient with ulcerative colitis.Which food selection by the patient indicates to the nurse that the patient understands the prescribed diet?

The nurse is teaching an older client about the prevention of osteoporosis.Which foods should the nurse recommend to the client to increase in the diet?

The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management.Which response by the client indicates understanding?

What advice should a nurse give to a patient who is about to undergo a cystoscopy?

A patient arrives at the emergency department experiencing chest pain after taking sildenafil.Based on the patient’s history, which medication should the nurse withhold?