NCLEX - Pediatrics - Oncology
The nurse is providing home care instructions to the mother of a child receiving radiation therapy. Which statement by the mother indicates a need for further teaching? 1."I should dress my child in loose-fitting clothing." 2."I won't need to limit the amount of sun that my child gets." 3."My child may experience fatigue and need more rest periods." 4."I need to try to provide food and fluids to prevent dehydration."
Correct Answer: 2 Rationale: Sun protection is essential during radiation treatments. The child should not be exposed to sun during these treatments because of the risk of an alteration of skin integrity. The statements in the remaining options reflect appropriate measures for the child during radiation therapy
A child is scheduled for allogeneic bone marrow transplantation (BMT). The parent of the child asks the nurse about the procedure. The nurse should provide which description about the BMT? 1.Aspiration of bone marrow from the child 2.Obtaining bone marrow from the child's twin 3.Obtaining bovine (cow) bone marrow and administering it to the child 4.Obtaining bone marrow from a donor who matches the child's tissue type
Correct Answer: 4 Rationale: In allogeneic BMT, a donor who matches the child's tissue type is found. That bone marrow is then given to the child. In autologous BMT, the child undergoes general anesthesia for aspiration of his or her bone marrow, which is then processed in the laboratory and frozen until that marrow needs to be infused back into the child. Syngeneic BMT is done when the child has an identical twin. Administering bovine bone marrow to the child is not used in BMT.
A 9-year-old child with leukemia is in remission and has returned to school. The school nurse calls the mother of the child and tells the mother that a classmate has just been diagnosed with chickenpox. The mother immediately calls the clinic nurse because the leukemic child has never had chickenpox. Which is an appropriate response by the clinic nurse to the mother? 1."There is no need to be concerned." 2."Bring the child into the clinic for a vaccine." 3."Keep the child out of school for a 2-week period." 4."Monitor the child for an elevated temperature, and call the clinic if this happens."
Correct Answer: 2 Rationale: Immunocompromised children are unable to fight varicella adequately. Chickenpox can be deadly to the immunocompromised child. If an immunocompromised child who has not had chickenpox is exposed to someone with varicella, the child should receive varicella-zoster immune globulin within 96 hours of exposure. All other options are incorrect because they do nothing to minimize the chances of developing the disease.
The nurse is caring for a 9-year-old child with leukemia who is hospitalized for the administration of chemotherapy. The nurse would monitor the child specifically for central nervous system involvement by checking which item? 1.Pupillary reaction 2.Level of consciousness 3.The presence of petechiae in the sclera 4.Color, motion, and sensation of the extremities
Correct Answer: 2 Rationale: The central nervous system (CNS) status is monitored in the child with leukemia because of the risk of infiltration of blast cells into the CNS. The nurse should check the child's level of consciousness (LOC) and should also monitor for signs of irritability, vomiting, and lethargy. Changes in pupillary reaction are specific to conditions related to increased intracranial pressure. The presence of petechiae in the sclera is an objective sign that may be noted in leukemia but is not specifically related to the CNS. Color, motion, and sensation of the extremities relate to a neurovascular assessment and are not specifically related to CNS status.
The nurse instructs the parents of a child with leukemia regarding measures related to monitoring for infection. Which statement, if made by the parent, indicates a need for further instructions? 1."I will take a rectal temperature daily." 2."I will inspect the skin daily for redness." 3."I will inspect the mouth daily for lesions." 4."I will perform proper hand washing techniques."
Correct Answer: 1 Rationale: Leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the bone marrow. The risk of injury to fragile mucous membranes and resultant bleeding is so high in the child with leukemia that tympanic or axillary temperatures should be taken. In addition, rectal abscesses can occur easily to damaged rectal tissue. No rectal temperatures should be taken. In addition, oral temperature taking should be avoided, especially if the child has oral ulcers. All other options are appropriate measures to prevent infection.
The nurse has reviewed the health care provider's prescriptions for a child suspected of a diagnosis of neuroblastoma and is preparing to implement diagnostic procedures that will confirm the diagnosis. What should the nurse expect to do next to assist in confirming the diagnosis? 1.Collect a 24-hour urine sample. 2.Perform a neurological assessment. 3.Assist with a bone marrow aspiration. 4.Send to the radiology department for a chest x-ray.
Correct Answer: 1 Rationale: Neuroblastoma is a solid tumor found only in children. It arises from neural crest cells that develop into the sympathetic nervous system and the adrenal medulla. Typically, the tumor infringes on adjacent normal tissue and organs. Neuroblastoma cells may excrete catecholamines and their metabolites. Urine samples will indicate elevated vanillylmandelic acid levels. A bone marrow aspiration will assist in determining marrow involvement. A neurological examination and a chest x-ray may be performed but will not confirm the diagnosis.
The nurse is monitoring a 3-year-old child for signs and symptoms of increased intracranial pressure (ICP) after a craniotomy. The nurse plans to monitor for which early sign or symptom of increased ICP? 1.Vomiting 2.Bulging anterior fontanel 3.Increasing head circumference 4.Complaints of a frontal headache
Correct Answer: 1 Rationale: The brain, although well protected by the solid bony cranium, is highly susceptible to pressure that may accumulate within the enclosure. Volume and pressure must remain constant within the brain. A change in the size of the brain, such as occurs with edema or increased volume of intracranial blood or cerebrospinal fluid without a compensatory change, leads to an increase in ICP, which may be life-threatening. Vomiting, an early sign of increased ICP, can become excessive as pressure builds up and stimulates the medulla in the brainstem, which houses the vomiting center. Children with open fontanels (posterior fontanel closes at 2 to 3 months; anterior fontanel closes at 12 to 18 months) compensate for ICP changes by skull expansion and subsequent bulging fontanels. When the fontanels have closed, nausea, excessive vomiting, diplopia, and headaches become pronounced, with headaches becoming more prevalent in older children.
The mother of a 4-year-old child tells the pediatric nurse that the child's abdomen seems to be swollen. During further assessment of subjective data, the mother tells the nurse that the child is eating well and that the activity level of the child is unchanged. The nurse, suspecting the possibility of Wilms' tumor, should avoid which during the physical assessment? 1.Palpating the abdomen for a mass 2.Assessing the urine for the presence of hematuria 3.Monitoring the temperature for the presence of fever 4.Monitoring the blood pressure for the presence of hypertension
Correct Answer: 1 Rationale: Wilms' tumor is the most common intraabdominal and kidney tumor of childhood. If Wilms' tumor is suspected, the tumor mass should not be palpated by the nurse. Excessive manipulation can cause seeding of the tumor and spread of the cancerous cells. Hematuria, fever, and hypertension are clinical manifestations associated with Wilms' tumor.
The mother of a 4-year-old child tells the pediatric nurse that the child's abdomen seems to be swollen. During further assessment, the mother tells the nurse that the child is eating well and that the activity level of the child is unchanged. The nurse, suspecting the possibility of Wilms' tumor, should avoid which during the physical assessment? 1.Palpating the abdomen for a mass 2.Assessing the urine for the presence of hematuria 3.Monitoring the temperature for the presence of fever 4.Monitoring the blood pressure for the presence of hypertension
Correct Answer: 1 Rationale: Wilms' tumor is the most common intraabdominal and kidney tumor of childhood. If Wilms' tumor is suspected, the tumor mass should not be palpated by the nurse. Excessive manipulation can cause seeding of the tumor and spread of the cancerous cells. Hematuria, fever, and hypertension are clinical manifestations associated with Wilms' tumor.
A 14-year-old child is admitted to the hospital with a diagnosis of acute lymphocytic leukemia. She is receiving a combination chemotherapeutic regimen that includes cyclophosphamide. The nurse plans care understanding that which are associated with this medication? Select all that apply. 1.It is platelet sparing. 2.It causes constipation. 3.It causes hemorrhagic cystitis. 4.It causes bone marrow depression. 5.Increased fluid intake is necessary.
Correct Answer: 1,3,4,5 Rationale: Cyclophosphamide is an alkylating agent used as a chemotherapeutic agent in children with leukemia and other cancers. It also causes hemorrhagic cystitis; therefore, increased fluid intake is necessary. It does not cause constipation. Its side/adverse effects include bone marrow depression (BMD), but it is platelet sparing.
The nurse is performing an assessment on a 10-year-old child suspected to have Hodgkin's disease. Which assessment findings are specifically characteristic of this disease? Select all that apply. 1.Abdominal pain 2.Fever and malaise 3.Anorexia and weight loss 4.Painful, enlarged inguinal lymph nodes 5.Painless, firm, and movable adenopathy in the cervical area
Correct Answer: 1,5 Rationale: Hodgkin's disease (a type of lymphoma) is a malignancy of the lymph nodes. Specific clinical manifestations associated with Hodgkin's disease include painless, firm, and movable adenopathy in the cervical and supraclavicular areas and abdominal pain as a result of enlarged retroperitoneal nodes. Hepatosplenomegaly also is noted. Although fever, malaise, anorexia, and weight loss are associated with Hodgkin's disease, these manifestations are seen in many disorders.
A 13-year-old child is diagnosed with Ewing's sarcoma of the femur. After a course of radiation and chemotherapy, it was decided that leg amputation is necessary. After the amputation, the child becomes very frightened because of aching and cramping felt in the missing limb. Which nursing statement is most appropriate to assist in alleviating the child's fear? 1."The pain medication that I give you will take these feelings away." 2."This aching and cramping is normal and temporary and will subside." 3."This pain is not real pain, and relaxation exercises will help it go away." 4."This normally occurs after the surgery, and we will teach you ways to deal with it."
Correct Answer: 2 Rationale: After amputation, phantom limb pain is a temporary condition that some children experience. This sensation of burning, aching, or cramping in the missing limb is distressing to the child. The child needs to be reassured that the condition is normal and only temporary. All other options are not appropriate responses to the child, as they are incorrect or inappropriate statements.
A 4-year-old child is admitted to the hospital for abdominal pain. The mother reports that the child has been pale and excessively tired and is bruising easily. On physical examination, lymphadenopathy and hepatosplenomegaly are noted. Diagnostic studies are being performed because acute lymphocytic leukemia is suspected. The nurse determines that which laboratory result confirms the diagnosis? 1.Lumbar puncture showing no blast cells 2.Bone marrow biopsy showing blast cells 3.Platelet count of 350,000 mm3 (350 × 109/L) 4.White blood cell count 4,500 mm3 (4.5 × 109/L)
Correct Answer: 2 Rationale: Leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the bone marrow. The confirmatory test for leukemia is microscopic examination of bone marrow obtained by bone marrow aspirate and biopsy, which is considered positive if blast cells are present. An altered platelet count occurs as a result of the disease, but also may occur as a result of chemotherapy and does not confirm the diagnosis. The white blood cell count may be normal, high, or low in leukemia. A lumbar puncture may be done to look for blast cells in the spinal fluid that indicate central nervous system disease.
The nurse provides a teaching session to the nursing staff regarding osteosarcoma. Which statement by a member of the nursing staff indicates a need for information? 1."The femur is the most common site of this sarcoma." 2."The child does not experience pain at the primary tumor site." 3."Limping, if a weight-bearing limb is affected, is a clinical manifestation." 4."The symptoms of the disease in the early stage are almost always attributed to normal growing pains."
Correct Answer: 2 Rationale: Osteosarcoma is the most common bone cancer in children. Cancer usually is found in the metaphysis of long bones, especially in the lower extremities, with most tumors occurring in the femur. Osteosarcoma is manifested clinically by progressive, insidious, and intermittent pain at the tumor site. By the time these children receive medical attention, they may be in considerable pain from the tumor. Options 1, 3, and 4 are accurate regarding osteosarcoma.
The pediatric nurse specialist provides a teaching session to the nursing staff regarding osteosarcoma. Which statement by a member of the nursing staff indicates a need for information? 1."The femur is the most common site of this sarcoma." 2."The child does not experience pain at the primary tumor site." 3."Limping, if a weight-bearing limb is affected, is a clinical manifestation." 4."The symptoms of the disease in the early stage are almost always attributed to normal growing pains."
Correct Answer: 2 Rationale: Osteosarcoma is the most common bone cancer in children. Cancer usually is found in the metaphysis of long bones, especially in the lower extremities, with most tumors occurring in the femur. Osteosarcoma is manifested clinically by progressive, insidious, and intermittent pain at the tumor site. By the time these children receive medical attention, they may be in considerable pain from the tumor. The statements in the remaining options are accurate regarding osteosarcoma.
Which specific nursing interventions are implemented in the care of a child with leukemia who is at risk for infection? Select all that apply. 1.Maintain the child in a semiprivate room. 2.Reduce exposure to environmental organisms. 3.Use strict aseptic technique for all procedures. 4.Ensure that anyone entering the child's room wears a mask. 5.Apply firm pressure to a needle-stick area for at least 10 minutes.
Correct Answer: 2,3,4 Rationale: Leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the bone marrow. It affects the bone marrow, causing anemia from decreased erythrocytes, infection from neutropenia, and bleeding from decreased platelet production (thrombocytopenia). A common complication of treatment for leukemia is overwhelming infection secondary to neutropenia. Measures to prevent infection include the use of a private room, strict aseptic technique, restriction of visitors and health care personnel with active infection, strict hand washing, ensuring that anyone entering the child's room wears a mask, and reducing exposure to environmental organisms by eliminating raw fruits and vegetables from the diet and fresh flowers from the child's room and by not leaving standing water in the child's room. Applying firm pressure to a needle-stick area for at least 10 minutes is a measure to prevent bleeding.
A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and protective isolation procedures are initiated. The grandmother of the child visits and brings a fresh bouquet of flowers picked from her garden, and asks the nurse for a vase for the flowers. Which response should the nurse provide to the grandmother? 1."I have a vase in the utility room, and I will get it for you." 2."I will get the vase and wash it well before you put the flowers in it." 3."The flowers from your garden are beautiful, but should not be placed in the child's room at this time." 4."When you bring the flowers into the room, place them on the bedside stand as far away from the child as possible."
Correct Answer: 3 Rationale: Leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the bone marrow. It affects the bone marrow, causing anemia from decreased erythrocytes, infection from neutropenia, and bleeding from decreased platelet production (thrombocytopenia). For a hospitalized neutropenic child, flowers or plants should not be kept in the room because standing water and damp soil harbor Aspergillus and Pseudomonas aeruginosa, to which the child is susceptible. In addition, fresh fruits and vegetables harbor molds and should be avoided until the white blood cell count increases.
In caring for a child diagnosed with Hodgkin's disease. Which oncologic emergency should the nurse be most concerned about? 1.Hyperleukocytosis 2.Spinal cord compression 3.Superior vena cava syndrome 4.Disseminated intavascular coagulation
Correct Answer: 3 Rationale: Pediatric oncologic emergencies include tumor lysis syndrome, hyperleukocytosis, superior vena cava syndrome, spinal cord compression, and disseminated intravascular coagulation. Because Hodgkin's disease causes a space-occupying lesion in the chest, superior vena cava syndrome is the most likely emergency that will occur with this type of malignancy. This complication could lead to airway compromise and respiratory failure. The other complications are possible, due to issues with immune response, treatment response, and obstruction, but are less likely to occur due to lesion location in Hodgkin's disease.
The nurse is collecting data on a 9-year-old child suspected of having a brain tumor. Which question should the nurse ask to elicit data related to the classic symptoms of a brain tumor? 1."Do you have trouble seeing?" 2."Do you feel tired all the time?" 3."Do you throw up in the morning?" 4."Do you have headaches late in the day?"
Correct Answer: 3 Rationale: The classic symptoms of children with brain tumors are headache and morning vomiting related to the child getting out of bed. Headaches worsen on arising but improve during the day. Fatigue may occur but is a vague symptom. Visual changes may occur, including nystagmus, diplopia, and strabismus, but these signs are not the hallmark symptoms with a brain tumor.
A diagnosis of Hodgkin's disease is suspected in a 12-year-old child. Several diagnostic studies are performed to determine the presence of this disease. Which diagnostic test result will confirm the diagnosis of Hodgkin's disease? 1.Elevated vanillylmandelic acid urinary levels 2.The presence of blast cells in the bone marrow 3.The presence of Epstein-Barr virus in the blood 4.The presence of Reed-Sternberg cells in the lymph nodes
Correct Answer: 4 Rationale: Hodgkin's disease (a type of lymphoma) is a malignancy of the lymph nodes. The presence of giant, multinucleated cells (Reed-Sternberg cells) is the classic characteristic of this disease. Elevated levels of vanillylmandelic acid in the urine may be found in children with neuroblastoma. The presence of blast cells in the bone marrow indicates leukemia. Epstein-Barr virus is associated with infectious mononucleosis.
The nurse is asked to prepare for the admission of a child to the pediatric unit with a diagnosis of Wilms' tumor. The nurse is creating a plan of care for the child and should include which intervention in the plan? 1.Monitor the temperature for hypothermia. 2.Monitor the blood pressure for hypotension. 3.Palpate the abdomen for an increase in the size of the tumor. 4.Inspect the urine for the presence of hematuria at each voiding.
Correct Answer: 4 Rationale: If Wilms' tumor is suspected, the tumor mass should not be palpated. Excessive manipulation can cause seeding of the tumor and cause spread of the cancerous cells. Fever (not hypothermia), hematuria, and hypertension (not hypotension) are clinical manifestations associated with Wilms' tumor.
A diagnostic workup is being performed on a 1-year-old child with suspected neuroblastoma. The nurse reviews the results of the diagnostic tests and understands that which finding is most specifically related to this type of tumor? 1.Positive Babinski's sign 2.Presence of blast cells in the bone marrow 3.Projectile vomiting, usually in the morning 4.Elevated vanillylmandelic acid urinary levels
Correct Answer: 4 Rationale: Neuroblastoma is a solid tumor found only in children. It arises from neural crest cells that develop into the sympathetic nervous system and the adrenal medulla. Typically, the tumor compresses adjacent normal tissue and organs. Neuroblastoma cells may excrete catecholamines and their metabolites. Urine samples will indicate elevated vanillylmandelic acid levels. The presence of blast cells in the bone marrow occurs in leukemia. Projectile vomiting occurring most often in the morning and a positive Babinski's sign are clinical manifestations of a brain tumor.
The nurse is caring for a 3-year-old boy with a diagnosis of acute lymphocytic leukemia. The child is crying and complaining that his knees hurt. Which nursing intervention is most appropriate? 1.Administer acetaminophen to the child. 2.Involve the child in a diversional activity. 3.Ask the child if he would like a "baby aspirin." 4.Apply heat to the child's knees and elevate the knees on a pillow.
Correct Answer: 1 Rationale: Acetaminophen is acceptable and does not have anticoagulant properties. Diversional activities would not relieve the pain. Aspirin is not administered to the child with acute lymphocytic leukemia (ALL) because of its anticoagulant properties, and administering aspirin could lead to bleeding in the joints. Heat also would increase the pain by increasing circulation to the area.
The nurse analyzes the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse notes that the platelet count is 19,500 mm3 (19.5 × 109/L). On the basis of this laboratory result, which intervention should the nurse include in the plan of care? 1.Initiate bleeding precautions. 2.Monitor closely for signs of infection. 3.Monitor the temperature every 4 hours. 4.Initiate protective isolation precautions.
Correct Answer: 1 Rationale: Leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the bone marrow. It affects the bone marrow, causing anemia from decreased erythrocytes, infection from neutropenia, and bleeding from decreased platelet production (thrombocytopenia). If a child is severely thrombocytopenic and has a platelet count less than 20,000 mm3 (20.0 × 109/L), bleeding precautions need to be initiated because of the increased risk of bleeding or hemorrhage. Precautions include limiting activity that could result in head injury, using soft toothbrushes, checking urine and stools for blood, and administering stool softeners to prevent straining with constipation. In addition, suppositories, enemas, and rectal temperatures are avoided. Options 2, 3, and 4 are related to the prevention of infection rather than bleeding.
Nursing care of the child with myelosuppression from leukemia or chemotherapeutic agents should include which intervention? 1.Restrict oral fluids. 2.Use good hand washing technique. 3.Give immunizations appropriate for age. 4.Institute strict isolation with no visitors allowed.
Correct Answer: 2 Rationale: A child with myelosuppression is at risk for infection. Good hand washing technique is necessary to prevent the spread of infection. Restricting oral fluids would not be an intervention to reduce the risk of infection and could actually be harmful to the child. Live virus vaccines are not given when the child is myelosuppressed, so assessment of the child's immune status should be done before administration of immunizations appropriate for age. Strict isolation without visitors is not warranted, although visitors should wear a mask and gloves while in the child's room.
A 6-year-old child has just been diagnosed with localized Hodgkin's disease, and chemotherapy is planned to begin immediately. The mother of the child asks the nurse why radiation therapy was not prescribed as a part of the treatment. What is the nurse's best response? 1."It's very costly, and chemotherapy works just as well." 2."I'm not sure. I'll discuss it with the health care provider." 3."Sometimes age has to do with the decision for radiation therapy." 4."The health care provider would prefer that you discuss treatment options with the oncologist."
Correct Answer: 3 Rationale: Radiation therapy is usually delayed until a child is 8 years old, whenever possible, to prevent retardation of bone growth and soft tissue development. Options 1, 2, and 4 are inappropriate responses to the mother and place the mother's question on hold.
The nurse is reviewing the record of a 10-year-old child suspected of having Hodgkin's disease. Which characteristic manifestation should the nurse anticipate to be documented in the assessment notes? 1.Fever 2.Malaise 3.Painful lymph nodes in the supraclavicular area 4.Painless and movable lymph nodes in the cervical area
Correct Answer: 4 Rationale: Clinical manifestations specifically associated with Hodgkin's disease include painless, firm, and movable adenopathy in the cervical and supraclavicular areas. Hepatosplenomegaly is also noted. Although anorexia, weight loss, fever, and malaise are associated with Hodgkin's disease, these manifestations are vague and can be seen in many disorders.
The nurse is reviewing the laboratory and diagnostic test results of a 5-year-old child scheduled to be seen in the clinic. The nurse notes that the health care provider documented that diagnostic studies revealed the presence of Reed-Sternberg cells. The nurse prepares to assist the health care provider to discuss which initial procedure with the parents? 1.Chemotherapy 2.Surgical biopsy 3.High-dose radiation 4.Intravenous antibiotics
Correct Answer: 1 Rationale: Hodgkin's disease is a neoplasm of lymphatic tissue. The presence of giant, multinucleated cells (Reed-Sternberg cells) is the hallmark of this disease. Initially the nurse should prepare the child for diagnostic procedures and a surgical biopsy. Once Hodgkin's disease is confirmed, induction chemotherapy is then begun as soon as the child is stable and staging of the disease has been completed. High-dose radiation may be used if the disease is detected in a single site or in full-grown adolescents but usually is not the initial treatment in small children. Hodgkin's disease is cancer, not a bacterial infection.
The pediatric nurse clinician is discussing the pathophysiology related to childhood leukemia with a class of nursing students. Which statement made by a nursing student indicates a need for further teaching of the pathophysiology of this disease? 1.The platelet count is decreased. 2.Red blood cell production is affected. 3.Reed-Sternberg cells are found on biopsy. 4.Normal bone marrow is replaced by blast cells.
Correct Answer: 3 Rationale: In leukemia, normal bone marrow is replaced by malignant blast cells. As the blast cells take over the bone marrow, eventually red blood cell and platelet production is affected, and the child becomes anemic and thrombocytopenic. The Reed-Sternberg cell is found in Hodgkin's disease.
The nurse is monitoring for bleeding in a child following surgery for removal of a brain tumor. The nurse checks the head dressing and notes the presence of dried blood on the back of the dressing. The child is alert and oriented, and the vital signs and neurological signs are stable. Which nursing action is most appropriate initially? 1.Prepare to change the dressing. 2.Recheck the dressing in 1 hour. 3.Check the operative record to determine whether a drain is in place. 4.Document the findings and notify the health care provider immediately.
Correct Answer: 3 Rationale: The initial nursing action is to determine whether a drain is in place because the drainage seen on the dressing could be attributed to this. The nurse would not change the dressing without a health care provider's prescription. Rechecking the dressing is an appropriate action, but it is not the initial action. The findings would be documented; however, there is no reason to notify the health care provider immediately. The initial action would be to further assess the cause of the drainage.
The nurse is monitoring a child for bleeding after surgery for removal of 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 intervention should the nurse perform immediately? 1.Reinforce the dressing. 2.Notify the health care provider (HCP). 3.Document the findings and continue to monitor. 4.Circle the area of drainage and continue to monitor.
Correct Answer: 2 Rationale: Colorless drainage on the dressing in a child after craniotomy indicates the presence of cerebrospinal fluid and should be reported to the HCP immediately. Options 1, 3, and 4 are not the immediate nursing intervention because they do not address the need for immediate intervention to prevent complications.
The pediatric nurse assists the health care provider in performing a lumbar puncture on a 3-year-old child with leukemia and suspected central nervous system metastasis. The nurse should place the child in which position for this procedure? 1.Lithotomy position 2.Modified Sims' position 3.Lateral recumbent, knees flexed to the abdomen and the head bent, chin down 4.Prone, with the knees flexed to the abdomen and the head bent, the chin resting on the chest
Correct Answer: 3 Rationale: A lateral recumbent position, with the knees flexed to the abdomen and the head bent with the chin resting on the chest, is assumed for a lumbar puncture. This position separates the spinal processes and facilitates needle insertion into the subarachnoid space. The remaining options are incorrect positions.
