ATI LPN
Hematologic System Assessment Questions Questions
Question 1 of 5
A child with acute glomerulonephritis is in the playroom and experiences blurred vision and headache. Which of the following actions should be taken by the nurse?
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.
Question 2 of 5
The nurse is providing instruction to the parents of an infant with a colostomy. Which statement by the parents’ indicates appropriate understanding of the teaching session?
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.
Question 3 of 5
During a 4-month-old’s well-child check, the nurse discusses introduction of solid foods into the infant’s diet and concerns for foods commonly associated with food allergies. Due to allergies, which foods will the nurse instruction the parents to avoid until after 1 year of age?
Correct Answer: A
Rationale: The correct answer is A (Strawberries, eggs, and wheat) because these foods are common allergens that should be avoided until after 1 year of age to reduce the risk of food allergies. Strawberries are highly allergenic, eggs contain proteins that may trigger allergies, and wheat contains gluten which can cause sensitivities. Peas, tomatoes, and spinach (choice B) are generally safe to introduce to infants. Carrots, beets, and spinach (choice C) are also safe options. Squash, pork, and tomatoes (choice D) are not commonly associated with food allergies in infants.
Question 4 of 5
Which is the priority concern in developing a teaching plan for the parents of a 15-month-old child?
Correct Answer: D
Rationale: The correct answer is D, instructions on a home safety assessment. This is the priority concern because at 15 months, children are curious and mobile, making them prone to accidents. Conducting a home safety assessment helps identify potential hazards and allows parents to make necessary changes to create a safe environment for the child. Toilet training (A) and weaning from bottles (B) are important developmental milestones but are not as critical as ensuring the child's safety. Preschool readiness (C) is also important but can be addressed later, whereas immediate attention to home safety is crucial to prevent accidents.
Question 5 of 5
A chest x-ray examination is ordered for a child with suspected cardiac problems. The child’s parent asks the nurse, 'What will the x-ray show about the heart?' The nurse’s response should be based on knowledge that the x-ray film will do which of the following?
Correct Answer: D
Rationale: The correct answer is D: Provide information on heart size and pulmonary blood flow patterns. A chest x-ray can reveal the size of the heart and indicate any abnormalities in the pulmonary blood flow patterns. This is important in assessing cardiac function. A: Show bones of chest but not the heart - This is incorrect as a chest x-ray can show the heart along with the bones of the chest. B: Evaluate the vascular anatomy outside of the heart - This is incorrect as a chest x-ray primarily focuses on the heart and lungs. C: Show a graphic measure of electrical activity of the heart - This is incorrect as an ECG (electrocardiogram) is used to measure the electrical activity of the heart, not a chest x-ray.