ATI RN
Maternity and Pediatric Nursing 4th Edition Test Bank Questions
Question 1 of 5
A 40 year-old female nurse had a fecal impaction and was admitted to the hospital. The physician orders an oil retention enema followed by a cleansing enema. What is the rationale for administering the oiul enema first?
Correct Answer: B
Rationale: The rationale for administering the oil retention enema first in this case is to help soften the fecal mass and lubricate the walls of the rectum and colon. This will make it easier for the impacted stool to be passed, reducing the risk of injury or discomfort during the procedure. The oil enema acts as a lubricant, making it easier for the hardened fecal mass to be expelled from the body without causing damage to the intestinal walls. Additionally, the oil enema helps to soften the fecal mass, further aiding in its removal.
Question 2 of 5
A client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume?
Correct Answer: B
Rationale: Increased urine osmolarity would best support the nursing diagnosis of Deficient fluid volume in a client with hyperglycemia. Hyperglycemia can lead to osmotic diuresis, where the body excretes excessive amounts of water to help eliminate glucose. This results in concentrated urine with a higher osmolarity. A high urine osmolarity indicates that the kidneys are conserving water due to decreased fluid volume in the body, supporting the diagnosis of Deficient fluid volume. The other assessment findings (cool, clammy skin, distended neck veins, serum sodium level) are not specific to the diagnosis of Deficient fluid volume in this context.
Question 3 of 5
A client with primary diabetes insipidus is ready for discharge on desmopressin (DDAVP). Which instruction should the nurse provide?
Correct Answer: C
Rationale: It is important for the nurse to instruct the client that they may not be able to use desmopressin nasally if they have nasal discharge or blockage. This is because nasal absorption is critical for the effectiveness of desmopressin, and any nasal issues may hinder proper absorption. If the client experiences nasal discharge or blockage, an alternative route for administering desmopressin may need to be considered, such as oral or injectable forms. This instruction is essential to ensure the client receives the medication effectively and manages their condition appropriately.
Question 4 of 5
The initial neurological symptom of Guilain-Barre Syndrome is:
Correct Answer: B
Rationale: The initial neurological symptom of Guillain-Barre Syndrome (GBS) is typically paresthesia, which is a tingling or numbness sensation in the legs. GBS is an autoimmune disorder that affects the peripheral nervous system, leading to muscle weakness and paralysis. As the condition progresses, symptoms may worsen and may include absent tendon reflexes, weakness in the arms and legs, and difficulty breathing. However, paresthesia is often one of the earliest and most common symptoms of GBS.
Question 5 of 5
A nurse finds Mr. Gabatan under the wreckage of the car. He is conscious, breathing satisfactorily, and lying on the back complaining of pain in the back and an inability to move his legs. The nurse should first:
Correct Answer: C
Rationale: The correct initial action in this scenario would be to roll Mr. Gabatan on his abdomen, placing a pad under his head, and covering him with any material available. This position is known as the recovery position, and it is important for individuals who have suspected spinal injuries. By rolling Mr. Gabatan onto his abdomen, it helps protect his spine and prevent further injury. Placing a pad under his head provides some support, and covering him with material helps to keep him warm and comfortable while waiting for additional help to arrive. It is crucial to avoid movement, especially if there is a suspected spinal injury, as moving the individual incorrectly can worsen the injury and lead to permanent damage.