Ricci Chapter 43 - Test Bank - 4th Edition || 100% Errorless
Answers.
1. The nurse is caring for a child who is experiencing an acute renal transplant rejection and is to
receive muromonab-CD3. What would the nurse most likely expect to assess after the first dose
is administered?
A. Fever with chills, chest tightness
B. Cough, hyperkalemia
C. Photosensitivity, gastrointestinal (GI) upset
D. Urinary retention, decreased appetite Correct Answer: A
Rationale: The first dose of muromonab-CD3 can cause fever, chills, chest tightness, wheezing,
nausea, and vomiting. Cough and hyperkalemia are associated with angiotensin-converting
enzyme inhibitors. Photosensitivity and GI upset are often associated with diuretics. Urinary
retention and decreased appetite are associated with imipramine.
2. The nurse is visually inspecting a urine specimen from a 12-year-old boy. The nurse
documents gross hematuria with a specimen of which color?
A. Cloudy yellow
B. Cola colored
C. Pale to almost clear urine
D. Light orange to moderately yellow colored Correct Answer: B
Rationale: Gross hematuria causes the urine to appear tea, cola, or even dirty green colored.
Cloudy urine is typically a sign of infection. Normal urine ranges from moderately yellow to pale
or almost clear. Orange-colored urine can occur because of medication.
3. The nurse is caring for a 4-year-old with a suspected urinary tract infection. What would be
most appropriate to say to the child when obtaining a urine specimen from him?
A. "I will need a urine sample."
B. "Let your mom help you tinkle in this cup."
C. "Please tinkle in this cup right now."
D. "Please void in this cup instead of the toilet." Correct Answer: B
Rationale: The nurse needs to use familiar terms to explain to the child what is needed and to
gain cooperation. The most positive approach would be to let the child's mother help rather than
demanding that he tinkle right now. Using the terms "urine sample" or "void" is not appropriate
for a 4-year-old.
4. The nurse is providing postsurgical care for an infant who has undergone a hypospadias repair.
Which action by the nurse would be most important to help keep the area clean while
maintaining proper position of the drainage tubing?
A. Keeping the drainage tube taped in an upright position
B. Administering antibiotics as ordered
C. Administering analgesics as prescribed
D. Using a double-diapering technique Correct Answer: D
Rationale: Double diapering is a method used to protect a child's urethra and stent or catheter
after surgery and additionally helps to keep the area clean and free from infection. Keeping the
drainage tube taped in an upright position, administering antibiotics, and administering
, analgesics are also important, but double diapering keeps the area clean and helps prevent
infection.
5. The nurse is caring for a 4-year-old girl with vulvovaginitis. After instructing the girl's mother
on how to help prevent subsequent episodes, which statement by the mother indicates a need for
additional teaching?
A. "She tells me she wipes from front to back."
B. "I will make sure she changes her underwear every day."
C. "She should avoid bubble baths."
D. "I will help supervise her wiping after bowel movements." Correct Answer: A
Rationale: At the age of 4, the mother should not assume that the girl will wipe properly. The
mother will need to supervise her wiping in order to train her properly. Making sure the child
changes her underwear daily, avoiding bubble baths, and supervising her wiping after bowel
movements indicate that the mother has understood the instructions.
6. A nurse is caring for a 7-year-old girl scheduled for an intravenous pyelogram (IVP). Which
action would be the priority before the test?
A. Checking with the parents for any allergies
B. Ensuring adequate hydration
C. Giving the girl an enema
D. Screening her for pregnancy Correct Answer: A
Rationale: It is important to double-check whether the girl has any allergies. The test is
contraindicated in children allergic to shellfish or iodine. Adequate hydration is also important,
but the check for allergies is a priority. Only females of reproductive age must be screened for
pregnancy. An enema is not necessary at all institutions.
7. A 6-year-old child has undergone a renal transplant and is receiving cyclosporine. The nurse
instructs the parents to be especially alert for which complication?
A. Weight loss
B. Hypotension
C. Signs of infection
D. Hair loss Correct Answer: C
Rationale: The parents should be especially alert for signs of infection as cyclosporine is an
immunosuppressant drug. Weight gain instead of weight loss, hypertension instead of
hypotension, and increased facial hair instead of hair loss are some other potential side effects.
8. The nurse is caring for a 12-year-old girl with nephrotic syndrome. The girl confides that she
feels like a "freak" compared to her peers because of her weight, edema, and moon face. Which
response by the nurse would be most appropriate?
A. "Let's put you in touch with some other girls who are also having the same body changes."
B. "Luckily, this is just a temporary, unfortunate part of your condition; you need to accept it."
C. "Your real friends do not care about your appearance and just want you to get well."
D. "You are beautiful in your own way; what matters is what is on the inside." Correct Answer:
A
Rationale: It is important to introduce the girl to other youngsters with chronic renal conditions
so she does not feel so isolated. Adolescents need interaction with peers. Telling the girl that this
Answers.
1. The nurse is caring for a child who is experiencing an acute renal transplant rejection and is to
receive muromonab-CD3. What would the nurse most likely expect to assess after the first dose
is administered?
A. Fever with chills, chest tightness
B. Cough, hyperkalemia
C. Photosensitivity, gastrointestinal (GI) upset
D. Urinary retention, decreased appetite Correct Answer: A
Rationale: The first dose of muromonab-CD3 can cause fever, chills, chest tightness, wheezing,
nausea, and vomiting. Cough and hyperkalemia are associated with angiotensin-converting
enzyme inhibitors. Photosensitivity and GI upset are often associated with diuretics. Urinary
retention and decreased appetite are associated with imipramine.
2. The nurse is visually inspecting a urine specimen from a 12-year-old boy. The nurse
documents gross hematuria with a specimen of which color?
A. Cloudy yellow
B. Cola colored
C. Pale to almost clear urine
D. Light orange to moderately yellow colored Correct Answer: B
Rationale: Gross hematuria causes the urine to appear tea, cola, or even dirty green colored.
Cloudy urine is typically a sign of infection. Normal urine ranges from moderately yellow to pale
or almost clear. Orange-colored urine can occur because of medication.
3. The nurse is caring for a 4-year-old with a suspected urinary tract infection. What would be
most appropriate to say to the child when obtaining a urine specimen from him?
A. "I will need a urine sample."
B. "Let your mom help you tinkle in this cup."
C. "Please tinkle in this cup right now."
D. "Please void in this cup instead of the toilet." Correct Answer: B
Rationale: The nurse needs to use familiar terms to explain to the child what is needed and to
gain cooperation. The most positive approach would be to let the child's mother help rather than
demanding that he tinkle right now. Using the terms "urine sample" or "void" is not appropriate
for a 4-year-old.
4. The nurse is providing postsurgical care for an infant who has undergone a hypospadias repair.
Which action by the nurse would be most important to help keep the area clean while
maintaining proper position of the drainage tubing?
A. Keeping the drainage tube taped in an upright position
B. Administering antibiotics as ordered
C. Administering analgesics as prescribed
D. Using a double-diapering technique Correct Answer: D
Rationale: Double diapering is a method used to protect a child's urethra and stent or catheter
after surgery and additionally helps to keep the area clean and free from infection. Keeping the
drainage tube taped in an upright position, administering antibiotics, and administering
, analgesics are also important, but double diapering keeps the area clean and helps prevent
infection.
5. The nurse is caring for a 4-year-old girl with vulvovaginitis. After instructing the girl's mother
on how to help prevent subsequent episodes, which statement by the mother indicates a need for
additional teaching?
A. "She tells me she wipes from front to back."
B. "I will make sure she changes her underwear every day."
C. "She should avoid bubble baths."
D. "I will help supervise her wiping after bowel movements." Correct Answer: A
Rationale: At the age of 4, the mother should not assume that the girl will wipe properly. The
mother will need to supervise her wiping in order to train her properly. Making sure the child
changes her underwear daily, avoiding bubble baths, and supervising her wiping after bowel
movements indicate that the mother has understood the instructions.
6. A nurse is caring for a 7-year-old girl scheduled for an intravenous pyelogram (IVP). Which
action would be the priority before the test?
A. Checking with the parents for any allergies
B. Ensuring adequate hydration
C. Giving the girl an enema
D. Screening her for pregnancy Correct Answer: A
Rationale: It is important to double-check whether the girl has any allergies. The test is
contraindicated in children allergic to shellfish or iodine. Adequate hydration is also important,
but the check for allergies is a priority. Only females of reproductive age must be screened for
pregnancy. An enema is not necessary at all institutions.
7. A 6-year-old child has undergone a renal transplant and is receiving cyclosporine. The nurse
instructs the parents to be especially alert for which complication?
A. Weight loss
B. Hypotension
C. Signs of infection
D. Hair loss Correct Answer: C
Rationale: The parents should be especially alert for signs of infection as cyclosporine is an
immunosuppressant drug. Weight gain instead of weight loss, hypertension instead of
hypotension, and increased facial hair instead of hair loss are some other potential side effects.
8. The nurse is caring for a 12-year-old girl with nephrotic syndrome. The girl confides that she
feels like a "freak" compared to her peers because of her weight, edema, and moon face. Which
response by the nurse would be most appropriate?
A. "Let's put you in touch with some other girls who are also having the same body changes."
B. "Luckily, this is just a temporary, unfortunate part of your condition; you need to accept it."
C. "Your real friends do not care about your appearance and just want you to get well."
D. "You are beautiful in your own way; what matters is what is on the inside." Correct Answer:
A
Rationale: It is important to introduce the girl to other youngsters with chronic renal conditions
so she does not feel so isolated. Adolescents need interaction with peers. Telling the girl that this
