Nursing Elites

1. A child is admitted to the hospital with a diagnosis of Wilms tumor, stage II. Which of the following statements most accurately describes this stage?

• A. The tumor is less than 3 cm in size and requires no chemotherapy.
• B. The tumor did not extend beyond the kidney and was completely resected.
• C. The tumor extended beyond the kidney but was completely resected.
• D. The tumor has spread into the abdominal cavity and cannot be resected.

Correct answer: C

Rationale: In Wilms tumor staging, stage II indicates that the tumor extends beyond the kidney but is completely resected. This means that the tumor has spread beyond the kidney but has been successfully removed. Choices A and B are incorrect because a tumor less than 3 cm in size and a tumor that did not extend beyond the kidney do not align with the characteristics of stage II Wilms tumor. Choice D is also incorrect as it describes a more advanced stage where the tumor has spread into the abdominal cavity and cannot be completely resected. Therefore, the correct answer is C, as it accurately reflects the characteristics of a stage II Wilms tumor.

2. A client complained of nausea, a metallic taste in her mouth, and fine hand tremors 2 hours after her first dose of lithium carbonate (Lithane). What is the nurse's best explanation of these findings?

• A. These side effects are common and should subside in a few days.
• B. The client is probably having an allergic reaction and should discontinue the drug.
• C. Taking the lithium on an empty stomach should decrease these symptoms.
• D. Decreasing dietary intake of sodium and fluids should minimize the side effects.

Correct answer: A

Rationale: The correct answer is, 'These side effects are common and should subside in a few days.' Nausea, metallic taste, and fine hand tremors are common side effects of lithium carbonate (Lithane) and typically diminish within a few days as the body adjusts to the medication. Option B is incorrect because these symptoms are not indicative of an allergic reaction. Option C is incorrect as taking lithium on an empty stomach does not directly address or decrease these specific side effects. Option D is also incorrect as reducing sodium and fluid intake is not the recommended approach to managing these particular side effects of lithium.

3. After surgery for an imperforate anus, an infant returns with a red and edematous colostomy stoma. What action should the nurse take based on this finding?

• A. Elevate the buttocks.
• B. Document the findings.
• C. Apply ice immediately.
• D. Call the primary health care provider.

Correct answer: B

Rationale: A red and edematous colostomy stoma is a common finding immediately after surgery, and these changes are expected to decrease over time. As the stoma heals, it usually becomes pink without signs of abnormal drainage, swelling, or skin breakdown. Therefore, the appropriate action for the nurse is to document these normal findings. Elevating the buttocks, applying ice, or calling the primary health care provider are unnecessary interventions at this stage.

4. The infant has a diagnosis of bladder exstrophy. To protect the exposed bladder tissue, what intervention should the nurse plan?

• A. Cover the bladder with petroleum jelly gauze.
• B. Cover the bladder with a non-adhering plastic wrap.
• C. Apply sterile distilled water dressings over the bladder mucosa.
• D. Keep the bladder tissue dry by covering it with dry sterile gauze.

Correct answer: C

Rationale: Bladder exstrophy is a condition where the bladder is exposed and external to the body. To protect the exposed bladder tissue from drying out while allowing urine drainage, it is best to cover the bladder with a non-adhering plastic wrap. Using petroleum jelly gauze should be avoided as it can dry out, adhere to the mucosa, and damage delicate tissue upon removal. Applying sterile distilled water dressings can also dry out and cause damage when removed. Keeping the bladder tissue dry with sterile gauze is not ideal as maintaining a moist environment is important for tissue protection in this case.

5. While caring for a patient with respiratory disease, the nurse observes that the patient's SpO2 drops from 93% to 88% while the patient is ambulating in the hallway. What is the priority action of the nurse?

• A. Notify the healthcare provider
• B. Document the response to exercise
• C. Administer the PRN supplemental O2
• D. Encourage the patient to pace activity

Correct answer: C

Rationale: The drop in SpO2 to 88% indicates that the patient is hypoxemic and needs supplemental oxygen when exercising. Administering PRN supplemental oxygen is the priority action to correct the hypoxemia and ensure adequate oxygenation during activity. Notifying the healthcare provider can be done after stabilizing the patient's oxygen levels. Documenting the response to exercise is important but secondary to addressing the immediate hypoxemia. Encouraging the patient to pace activity is not sufficient to address the acute drop in SpO2 and provide the necessary oxygen support.

Similar Questions