ATI LPN
Immune System Questions Questions
Question 1 of 5
A child with severe gastroenteritis is admitted to a semiprivate room on the pediatric unit. The charge nurse should place this client with which roommate?
Correct Answer: C
Rationale: The correct answer is C. Placing the child with another child with gastroenteritis is the best option to prevent transmission of the infection to other vulnerable patients. Choosing option A would risk exposing the child with meningitis to gastroenteritis. Option B involves a child with neutropenia who is immunocompromised and at high risk for infection. Option D may not be ideal as the child recovering from an appendectomy may have a weakened immune system and could be at risk for acquiring gastroenteritis. Placing the child with another case of gastroenteritis minimizes the risk of spreading the infection and ensures appropriate care and isolation measures are in place.
Question 2 of 5
A mother asks when toilet training is most appropriately initiated. What would be the nurse’s best response?
Correct Answer: B
Rationale: The correct answer is B because toilet training should be initiated when the child shows signs of physical and psychological readiness, such as staying dry for longer periods, showing interest in using the toilet, and being able to communicate their needs. This approach ensures a more successful and less stressful toilet training experience for both the child and the parent. Choice A is incorrect because starting toilet training based solely on age may not align with the child's individual readiness. Choice C is incorrect as walking ability does not necessarily indicate readiness for toilet training. Choice D is incorrect because the ability to sit on the potty for a specific time does not guarantee readiness for toilet training.
Question 3 of 5
The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells the nurse that her bandage is 'too wet.' The nurse finds the bandage and bed soaked with blood. The most appropriate initial nursing action is which of the following?
Correct Answer: D
Rationale: The correct initial nursing action is D: Apply direct pressure above catheterization site. This is the correct answer because applying direct pressure above the catheterization site will help control the bleeding and prevent further blood loss. Here is a step-by-step rationale: 1. Direct pressure is the first-line intervention for controlling bleeding. 2. It helps to promote clot formation and stop the bleeding. 3. Placing the child in Trendelenburg position is not indicated and can potentially worsen the situation by increasing blood flow to the site. 4. Applying a new bandage with more pressure can disrupt any clot formation and is not recommended as the first action. 5. Notifying the physician is important but should not be the initial action when dealing with active bleeding.
Question 4 of 5
Which of the following structural defects constitute tetralogy of Fallot?
Correct Answer: A
Rationale: The correct answer is A. In Tetralogy of Fallot, the four structural defects are: pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. Pulmonary stenosis leads to decreased blood flow to the lungs, ventricular septal defect causes mixing of oxygenated and deoxygenated blood, overriding aorta results in blood from both ventricles entering the aorta, and right ventricular hypertrophy occurs due to increased workload in pumping blood through the stenotic pulmonary valve. Choices B, C, and D do not include the correct combination of structural defects seen in Tetralogy of Fallot.
Question 5 of 5
An infant is receiving digoxin (Lanoxin) for congestive heart failure. The baby’s apical heart rate is assessed at 80 beats/minute. What intervention should the nurse implement?
Correct Answer: B
Rationale: The correct answer is B: Obtain a therapeutic drug level. The rationale for this is that digoxin has a narrow therapeutic range, and monitoring drug levels is crucial to prevent toxicity or subtherapeutic effects. By obtaining a drug level, the nurse can ensure that the infant is receiving the appropriate dose. A: Calling for a portable chest radiograph is not necessary for assessing the infant's heart rate in this scenario. C: Reassessing the heart rate in 30 minutes does not address the need to confirm the drug level for proper dosing. D: Administering digoxin immune Fab (Digibind) stat is a drastic measure for digoxin toxicity, which is not indicated based solely on the heart rate assessment at this time.