Ati/NCLex
A 4-year-old child is hospitalized with a suspected diagnosis of Wilms' tumor. The nurse reviews the plan of care and would question which intervention that is written in the plan?
Palpate the abdomen for a mass
The nurse reinforces home care instructions to the parents of a 3-year-old child who has been hospitalized with hemophilia. Which statement by a parent indicates the need for further teaching?
" I will avoid immunizations and dental hygiene treatments for my child."
A nurse is collecting data from a client who has anemia. Which of the following findings should the nurse expect?
Spoon-shaped nails
A nurse is reinforcing teaching for a client who is scheduled for a bone marrow biopsy of the iliac crest. Which of the following statements made by the client indicates an understanding of the teaching?
" I will need to stay in bed for about an hour after the test."
The nursing instructor asks a student nurse to describe osteogenic sarcoma. Which statement by the student indicates the need to further research the disease?
" The child does not experience pain at the primary tumor site."
A nurse is reinforcing preoperative teaching for a client who requests autologous donation in preparation for a scheduled orthopedic surgical procedure. Which of the following statements should the nurse include while reinforcing the teaching?
" You can donate blood during the weeks prior to surgery,"
The nurse reinforces instructions to the parents of a child with leukemia regarding measures related to monitoring for infection. Which statement by the parents indicates the need for further teaching?
" I need to take my child's rectal temperature daily."
A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following laboratory values is most useful to evaluate the intrinsic clotting cascade?
PTT
The nurse caring for a a child with aplastic anemia is reviewing the laboratory results and notes a white blood cell (WBC) count of 6000mm3 and a platelet count of 20,000 mm3. Which nursing intervention would be incorporated into the plan of care?
Encourage quiet play activities
The nurse reinforces instructions to the parents of a child with sickle cell anemia regarding the precipitation factors related to pain crisis. Which, if identified by a parent as a precipitating factor, indicates the need for further teaching?
Fluid overload
A nurse is reinforcing teaching with a client who has a new prescription for ferrous sulfate. Which of the following information should the nurse include?
Foods high in vitamin C will promote absorption
A nurse in a clinic is caring for a client who has suspected anemia. Which of the following laboratory test results should the nurse review?
Hgb 10 g/dL
A nurse is caring for a client who is receiving warfarin for anticoagulation therapy. Which of the following laboratory test results indicates to the nurse that the client needs an increase in the dosage?
INR 1.1
A nurse is assisting with the administration of packed RBCs to a client who has a Hgb of 6 g/dL. Which of the following actions should the nurse plan to take during the first 15 min of the transfusion?
Monitor the client for an acute hemolytic reaction
The nurse is monitoring for bleeding in a child after surgery to remove a brain tumor. The nurse checks the head dressing for the presence of blood and notes a colorless drainage on the back of the dressing. Which nursing action is appropriate?
Notify the registered nurse (RN)
A nurse is assisting the charge nurse with the administration of a blood transfusion to an older adult client. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?
Obtains vital signs frequently throughout the procedure
A nurse in a clinic receives a phone call from a client seeking information about a new prescription for erythropoietin. Which of the following information should the nurse review with the client?
The client should have their hemoglobin checked weekly until sable
The nurse observes a mother giving an oral iron supplement to her 6-year-old child with iron deficiency anemia. Which action by the mother indicates the need for further teaching?
The mother administered the iron with milk
The nurse is providing discharge instructions to the parents of a 14-year-old child who is undergoing radiation for Hodgkin's disease. Which statement by a parent indicates the need for further teaching?
" I will need to keep my child's skin from flaking, so we will be allowing showers every 2 or 3 days."
