ATI RN
Burns Pediatric Primary Care 7th Edition Test Bank Questions
Question 1 of 5
A 50-year-old African American patient is diagnosed with anemia. Where can the nurse assess for pallor?
Correct Answer: D
Rationale: When assessing for pallor in a patient with anemia, the nurse should specifically look at the conjunctivae (the membranes that cover the white part of the eyes). In individuals with anemia, the lack of red blood cells can result in paleness in the conjunctivae, which can be observed as a pale or whitish color. This area is especially useful for assessing pallor in individuals with darker skin tones, such as African Americans, where pallor may be less noticeable on other areas of the body.
Question 2 of 5
An adult is diagnosed with disseminated intravascular coagulation. The nurse should identify that the client is at risk for which of the following nursing diagnosis?
Correct Answer: C
Rationale: Disseminated intravascular coagulation (DIC) is a serious condition that involves widespread activation of coagulation leading to microthrombi formation in blood vessels throughout the body. This process can lead to consumption of clotting factors and platelets, causing both bleeding and thrombosis. In the context of DIC, there is a risk for altered tissue perfusion due to the combination of bleeding and microthrombi formation, which can impair blood flow to vital organs and tissues. This condition can ultimately result in organ dysfunction and failure, making it a significant concern in the care of a client with DIC. Therefore, the correct nursing diagnosis for a client with DIC is alteration in tissue perfusion related to bleeding and diminished blood flow.
Question 3 of 5
What is the most important postoperative instruction the nurse must give a client who has just returned from the operating room after receiving a subarachnoid block?
Correct Answer: D
Rationale: After receiving a subarachnoid block, the client may experience a sudden drop in blood pressure that can lead to complications such as dizziness or fainting upon standing. Therefore, it is crucial for the client to remain in a supine position for the duration specified by the physician to allow for proper monitoring and management of any potential postoperative complications. This instruction helps prevent the occurrence of hypotension and other adverse effects by allowing adequate time for the block to wear off and for the body to adjust to changes in blood pressure. It also ensures the safety and well-being of the client during the immediate postoperative period.
Question 4 of 5
The nurse is teaching a group of women to perform breast self-examination. The nurse should explain that the purpose of performing the examination is to discover:
Correct Answer: A
Rationale: The primary purpose of performing breast self-examination is to detect any abnormal changes in the breast tissue, including the presence of cancerous lumps. By regularly examining their breasts, women can become familiar with the normal look and feel of their breasts, making it easier to identify any new lumps or other changes that may indicate a potential problem, such as breast cancer. Detecting cancerous lumps early through self-examination can lead to early detection and improved treatment outcomes. It is important for women to perform breast self-examinations regularly and report any concerning findings to their healthcare provider for further evaluation.
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.