Ricci Chapter 43 - Test Bank - 4th Edition
UPDATED ACTUAL Exam Questions and
CORRECT 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 - 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 - 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 - 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 - 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."
UPDATED ACTUAL Exam Questions and
CORRECT 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 - 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 - 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 - 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 - 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."
