the nurse should tell the assistive personnel to remove which food from the childs food tray based on the prescribed treatment for nephrotic syndrome
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NCLEX RN Exam Review Answers

1. Which food should the assistive personnel be instructed to remove from the child's food tray based on the prescribed treatment for nephrotic syndrome?

Correct answer: A

Rationale: In nephrotic syndrome, a no-added-salt diet is recommended to manage the condition. High-sodium foods like pickles should be avoided as they can exacerbate fluid retention and swelling. Wheat toast, baked chicken, and steamed vegetables are generally suitable for individuals with nephrotic syndrome as they are low in sodium and protein, which are important considerations for this condition. Therefore, the correct choice is to remove the pickles from the child's food tray.

2. A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment?

Correct answer: A

Rationale: Paradoxic chest movement is the most concerning finding as it indicates a potential flail chest, which can lead to severe compromise in gas exchange and rapid hypoxemia. This condition requires immediate attention to prevent respiratory distress. Complaint of chest wall pain, a slightly elevated heart rate, and a large bruised area on the chest are important assessment findings but may not immediately threaten gas exchange or respiratory function. Therefore, identifying paradoxic chest movement is critical for prompt intervention and management.

3. Which finding is most important for the nurse to communicate to the health care provider about a patient who received a liver transplant 1 week ago?

Correct answer: C

Rationale: The correct answer is the patient's temperature of 100.8�F (38.2�C). In a patient who received a liver transplant 1 week ago, a fever is a significant finding that should be promptly communicated to the health care provider. Post-transplant patients are at high risk of infections, and fever can often be the initial indicator of an underlying infectious process. The other findings listed in choices A, B, and D are important and should be addressed, but they do not take precedence over a potential infection post-liver transplant. Dry palpebral and oral mucosa may indicate dehydration, crackles at bilateral lung bases may suggest fluid overload or infection, and no bowel movement for 4 days could indicate a bowel obstruction or ileus. However, in the context of a recent liver transplant, an elevated temperature is the most concerning and requires immediate attention to rule out infection.

4. A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment has been effective?

Correct answer: C

Rationale: The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed.

5. A nurse frequently treats patients in the 72-hour period after a stroke has occurred. The nurse would be most concerned about which of these assessment findings?

Correct answer: C

Rationale: The nurse would be most concerned about the assessment finding of an Intracranial Pressure (ICP) reading of 22 mmHg in a patient 72 hours post-stroke. Elevated ICP can indicate increased risk of edema and further brain damage. A target ICP should ideally be maintained at less than or equal to 15-20 mmHg. While the other options may also be important to monitor, an elevated ICP poses a more immediate threat to the patient's neurological status and requires prompt attention.

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