ATI RN
Burns Pediatric Primary Care 7th Edition Test Bank Questions
Question 1 of 5
A client is receiving a blood transfusion. If this client experiences an acute hemolytic reaction, which nursing intervention is the most important?
Correct Answer: D
Rationale: In the case of an acute hemolytic reaction during a blood transfusion, the most important nursing intervention is to immediately stop the transfusion and infuse normal saline solution. This is crucial to prevent further complications associated with the hemolysis of red blood cells. Normal saline helps maintain blood pressure and support kidney function, which may be compromised during a hemolytic reaction. Additionally, notifying the blood bank is important to investigate and prevent future reactions, and to determine if there was an error in blood compatibility. Administering antihistamines or changing the fluid type (such as dextrose 5% in water) will not address the underlying issue of hemolysis and may not be the most appropriate interventions in this scenario.
Question 2 of 5
Antibodies are made of which of the following types of substances?
Correct Answer: B
Rationale: Antibodies, also known as immunoglobulins, are proteins produced by the immune system in response to the presence of pathogens like bacteria, viruses, and other foreign substances. These proteins are specifically designed to recognize and bind to antigens, which are molecules that the immune system identifies as foreign or harmful. Antibodies play a crucial role in the immune response by marking pathogens for destruction by other immune cells and signaling the immune system to attack the invaders.
Therefore, antibodies are primarily made up of proteins.
Question 3 of 5
When educating parents regarding known antecedent infections in acute glomerulonephritis, which of the following should the nurse cover?
Correct Answer: B
Rationale: When educating parents regarding known antecedent infections in acute glomerulonephritis, the nurse should cover impetigo. Acute poststreptococcal glomerulonephritis (APSGN) is commonly triggered by a streptococcal infection, such as impetigo or strep throat. Impetigo, a superficial skin infection caused by Staphylococcus aureus or Streptococcus pyogenes, is a common precursor to APSGN in children.
Therefore, educating parents about impetigo and its potential link to acute glomerulonephritis is crucial in helping them recognize and manage their child's health effectively.
Question 4 of 5
In planning for the admission of this infant, the nurse's highest priority should be to:
Correct Answer: B
Rationale: When planning for the admission of an infant, the nurse's highest priority should be to turn on the apnea and cardiorespiratory monitors. Monitoring the baby's breathing and heart rate is crucial for assessing the infant's overall condition and detecting any signs of distress. This allows for early intervention if any issues arise and helps ensure the infant's safety and well-being. Once the monitors are on and the baby is stable, other interventions like providing oxygen or setting up an IV line can be addressed. However, monitoring the baby's vital signs takes precedence in ensuring immediate and continuous assessment.
Question 5 of 5
A client is receiving the cell cycle-nonspecific alkylating agent thiotepa (thioplex), 60 mg weekly for 4 weeks by bladder instillation as part of a chemotherapeutic regimen to treat bladder cancer. The client asks the nurse how the drug works. How does thiotepa exert its therapeutic effects?
Correct Answer: C
Rationale: Thiotepa is a cell cycle-nonspecific alkylating agent that exerts its therapeutic effects by interfering with both DNA replication and RNA transcription. The alkylating properties of thiotepa lead to the cross-linking of DNA strands, ultimately inhibiting DNA replication. Additionally, thiotepa can also disrupt RNA synthesis, further affecting protein production and cell function. This combined action on DNA replication and RNA transcription contributes to the cytotoxic effects of thiotepa on rapidly dividing cancer cells.