A client with disseminated intravascular coagulation (DIC) is anxious and has decreased oxygen saturation. Which is the priority nursing diagnosis for this client?

Correct Answer: B

Rationale: The priority nursing diagnosis for a client with DIC experiencing decreased oxygen saturation is Impaired Gas Exchange (B). This is because impaired gas exchange directly affects oxygenation, which is crucial for tissue perfusion and overall patient well-being. Addressing gas exchange will help improve oxygen saturation levels and prevent further complications. Pain (A) is important but not the priority in this case. Ineffective Tissue Perfusion (C) is related but secondary to impaired gas exchange. Anxiety (D) is also important but addressing oxygenation takes precedence for immediate patient safety.

Correct Answer: B

Rationale: The correct answer is B: Monitor for hematuria. Rhabdomyosarcoma is a type of cancer that originates from muscle tissue and can potentially lead to bleeding in the urine (hematuria). Monitoring for hematuria is crucial to assess the child's condition and detect any signs of complications. A: Positioning the child with the head elevated is not directly related to managing rhabdomyosarcoma. C: Demonstrating the use of a conformer is not relevant to the immediate nursing care for rhabdomyosarcoma. D: Administering oxygen may be necessary in some cases, but monitoring for hematuria is more specific and directly related to the potential complications of rhabdomyosarcoma.

Correct Answer: B

Rationale: The correct answer is B: Excess Fluid Volume Related to Decreased Plasma Filtration. In acute glomerulonephritis, the glomeruli are inflamed, leading to decreased filtration of plasma and retention of fluid. This results in excess fluid volume. This nursing diagnosis addresses the specific physiological issue of fluid retention in this condition. A: Risk for Urinary Tract Injury is not directly related to acute glomerulonephritis but rather to other factors such as urinary obstruction or trauma. C: Risk for Infection is not the priority nursing diagnosis in acute glomerulonephritis. Hypertension is a common complication, but infection risk is not directly related to the condition. D: Disturbed Personal Identity is not a relevant nursing diagnosis in this case as it does not address the physiological issue of fluid volume excess.

Correct Answer: A

Rationale: The correct answer is A: Anemia. End-stage renal failure leads to decreased production of erythropoietin, resulting in anemia. This causes a decrease in red blood cell production, leading to fatigue, weakness, and pale skin in the child. Explanation for why other choices are incorrect: B: Diarrhea is not typically associated with end-stage renal failure. C: Hypotension may occur in some cases of renal failure, but it is not a common problem in end-stage renal failure. D: Renal calculi are more common in conditions like kidney stones, which may lead to renal failure, but they are not directly expected in a child in end-stage renal failure.

Correct Answer: D

Rationale: The correct answer is D. Emesis after two feedings indicates that the infant is not tolerating the feedings well, which could be a sign of complications post-pyloromyotomy such as gastric outlet obstruction or poor stomach emptying. This warrants immediate attention to prevent further issues. A: Need for frequent burping is a common need for infants and does not necessarily indicate intolerance to feedings. B: Irritability during feeding could be due to various reasons such as hunger, discomfort, or gas, but it does not specifically indicate feeding intolerance. C: The passing of gas is a normal physiological process and does not directly indicate feeding intolerance. In summary, emesis after feedings is concerning as it suggests possible complications, while the other options are more commonly seen in infants and do not directly indicate feeding intolerance.