The nurse has identified Ineffective Tissue Perfusion as a nursing diagnosis for a client with disseminated intravascular coagulation (DIC). What intervention would be appropriate for the client?

Correct Answer: C

Rationale: The correct answer is C: Monitoring oxygen saturation. In DIC, there is impaired blood flow leading to inadequate perfusion of tissues. Monitoring oxygen saturation is crucial to assess tissue perfusion and ensure adequate oxygen delivery. This intervention directly addresses the underlying problem of ineffective tissue perfusion by evaluating the effectiveness of oxygenation. Repositioning the client every 2 hours (choice A) may help prevent pressure ulcers but does not directly address tissue perfusion. Administering oxygen (choice B) and encouraging deep breathing and coughing (choice D) may be beneficial but do not specifically target monitoring the client's oxygen saturation to evaluate tissue perfusion.

Correct Answer: C

Rationale: The correct answer is C: Leukemia. Leukemia is the most common form of childhood cancer, accounting for around 30% of all childhood cancers. It affects the blood and bone marrow, leading to abnormal production of white blood cells. Lymphoma (A) and brain tumors (B) are also common childhood cancers but not as prevalent as leukemia. Osteosarcoma (D) is a type of bone cancer that is rare in children compared to leukemia. Thus, based on the prevalence and incidence rates, leukemia is the most common form of childhood cancer.

Correct Answer: B

Rationale: The correct answer is B: Obtain a blood pressure on the child; notify the physician. Rationale: 1. Blurred vision and headache in a child with acute glomerulonephritis may indicate hypertension, a serious complication. 2. Obtaining a blood pressure reading is crucial to assess for hypertension, a common manifestation in glomerulonephritis. 3. Notify the physician immediately for further evaluation and management of the elevated blood pressure to prevent complications like hypertensive encephalopathy or seizures. Summary of other choices: A: Checking urine for increased hematuria is important but not the priority when the child is exhibiting symptoms of hypertension. C: Reassuring the child and encouraging bed rest does not address the potential serious complication of hypertension. D: Although obtaining serum electrolytes and sending a urinalysis are important in managing glomerulonephritis, addressing the acute symptoms of blurred vision and headache takes precedence.

Correct Answer: A

Rationale: The correct answer is A because carrots and green, leafy vegetables are high in potassium, which can exacerbate hyperkalemia in a child with renal failure. Carrots and green, leafy vegetables should be avoided to help manage potassium levels. Summary of other choices: B: Chips, cold cuts, and canned foods are high in sodium and phosphorus, not potassium. C: Spaghetti and meat sauce, breadsticks are moderate in potassium and can be included in the diet in moderation. D: Hamburger on a bun, cherry gelatin are lower in potassium compared to carrots and green, leafy vegetables.

Correct Answer: C

Rationale: The correct answer is C: "We will watch for skin irritation around the stoma." This statement indicates appropriate understanding because monitoring for skin irritation is essential in colostomy care to prevent complications. Skin irritation can occur due to leakage, improper fitting of the colostomy bag, or irritation from stool or urine. By closely observing the skin around the stoma, parents can detect early signs of irritation and take necessary actions to prevent skin breakdown. Incorrect Choices: A: Changing the colostomy bag with each wet diaper is unnecessary and may lead to increased skin irritation. B: Using adhesive enhancers without proper guidance can cause skin damage and is not a routine practice in colostomy care. D: Expecting a moderate amount of bleeding after cleansing the stoma area is incorrect as bleeding should be minimal. Monitoring for bleeding is important but expecting a moderate amount is not appropriate.