Page 2600 - Saunders Comprehensive Review For NCLEX-RN

Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Pediatrics: Oncological
Health Problem: Pediatric-Specific: Cancers
Priority Concepts: Development; Safety
Reference: McKinney et al. (2018), pp. 1146-1147.

901. Answer: 2

Rationale: A fresh colostomy stoma would be red and edematous, but this would
decrease with time. The colostomy site then becomes pink without evidence of
abnormal drainage, swelling, or skin breakdown. The nurse should document these
findings, because this is a normal expectation. Options 1, 3, and 4 are inappropriate
and unnecessary interventions.
Test-Taking Strategy: Focus on the subject, postoperative colostomy assessment.
Note the words returns from surgery. The nurse should expect redness and edema at
this time.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Pediatrics: Gastrointestinal
Health Problem: Pediatric-Specific: Gastrointestinal and Rectal problems
Priority Concepts: Clinical Judgment; Tissue Integrity
Reference: Perry et al. (2018), pp. 933, 938.

902. Answer: 3

Rationale: Low or oddly placed ears are associated with various congenital
defects and should be reported immediately. Although the findings should be
documented, the most appropriate action would be to notify the primary health care
provider. Options 2 and 4 are inaccurate and inappropriate nursing actions.
Test-Taking Strategy: Note the strategic words, most appropriate. Focus on the
subject, normal assessment findings in a newborn. Use knowledge regarding the
normal assessment findings in a newborn infant to answer this question. Recalling
that low-set ears are an abnormal finding will direct you to the correct option.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Maternity: Newborn
Health Problem: Pediatric-Specific: Disorders of prenatal development
Priority Concepts: Clinical Judgment; Development
Reference: McKinney et al. (2018), p. 437.

903. Answer: 1

Rationale: Jaundice, if present, is best assessed in the sclera, nail beds, and
mucous membranes. Generalized jaundice appears in the skin throughout the body.

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