ATI RN
Pediatric Nursing Cardiovascular NCLEX Practice Quiz Questions
Question 1 of 5
A client is brought to the ED by ambulance in cardiac arrest with cardiopulmonary resuscitation (CPR) in progress. The client is intubated and is receiving 100% oxygen per self-inflating (ambu) bag. The nurse determines that the client is cyanotic, cold, and diaphoretic. Which assessment is most important for the nurse to obtain?
Correct Answer: A
Rationale: In this scenario, the most important assessment for the nurse to obtain is breath sounds over bilateral lung fields (Option A). This assessment is crucial because the client is intubated and receiving 100% oxygen, so ensuring adequate ventilation and oxygenation is essential for the client's survival. Cyanosis, coldness, and diaphoresis can indicate poor oxygenation, which makes assessing breath sounds a priority to evaluate the effectiveness of ventilation. Option B, carotid pulsation during compressions, is not as critical in this situation because the client is already in cardiac arrest, and the priority is to focus on providing effective CPR and oxygenation. Deep tendon reflexes (Option C) and core body temperature (Option D) are also lower in priority compared to ensuring proper ventilation and oxygenation in a client in cardiac arrest. Educationally, this question highlights the importance of prioritizing assessments in emergency situations, understanding the significance of different assessment findings, and recognizing the immediate needs of a critically ill pediatric patient. Nurses need to be prepared to quickly assess and intervene to provide optimal care in such high-stress environments.
Question 2 of 5
While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?
Correct Answer: C
Rationale: In the context of caring for a client with Amyotrophic Lateral Sclerosis (ALS), the assessment finding that warrants immediate intervention by the nurse is option C) Weakened cough effort. This is because weakened cough effort in a client with ALS can lead to an increased risk of aspiration and respiratory complications due to compromised airway clearance. Option A) Inappropriate laughter may be a symptom of pseudobulbar affect, which can occur in ALS, but it is not immediately life-threatening and would not require urgent intervention. Option B) Increasing anxiety is a common emotional response in patients with chronic illnesses like ALS, but it does not require immediate intervention unless it is severe and impacting the patient's immediate safety. Option D) Asymmetrical weakness is a common symptom in ALS due to its progressive nature, but it does not warrant immediate intervention unless it is acutely worsening and affecting the patient's ability to breathe or maintain their airway. Educationally, it is essential for nurses to prioritize and recognize critical assessment findings in clients with ALS to prevent complications and provide timely interventions. Understanding the unique manifestations of ALS and their implications on the client's health is crucial for delivering safe and effective care in pediatric nursing practice.
Question 3 of 5
The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendations should the nurse encourage the client to follow?
Correct Answer: B
Rationale: In the context of pediatric nursing and cardiovascular health, the correct answer, option B, to encourage the client with glomerulonephritis to restrict protein intake by limiting meats and other high-protein foods is crucial due to the impaired kidney function associated with glomerulonephritis. Excessive protein can lead to increased waste products that the compromised kidneys may struggle to filter, worsening the condition. Option A, increasing intake of high-fiber foods, is not directly related to managing glomerulonephritis. While fiber is important for overall health, it is not a specific dietary recommendation for this condition. Option C, limiting oral fluid intake to 500 ml per day, is incorrect as fluid restriction is generally not recommended for clients with glomerulonephritis unless they have severe edema or are in end-stage renal failure. Fluid management is typically individualized based on the client's condition and kidney function. Option D, increasing intake of potassium-rich foods, such as bananas or cantaloupe, is not recommended for clients with glomerulonephritis, especially if they have hyperkalemia, a common complication in such cases. Excessive potassium intake can further burden the kidneys and lead to electrolyte imbalances. Educationally, understanding the rationale behind dietary recommendations for clients with glomerulonephritis is crucial for nurses caring for pediatric patients with this condition. By grasping the importance of protein restriction to alleviate the kidneys' workload, nurses can help manage and improve the client's health outcomes effectively.
Question 4 of 5
The nurse is completing the preoperative assessment of a client who is scheduled for a laparoscopic cholecystectomy under general anesthesia. Which finding warrants notification of the healthcare provider prior to proceeding with the scheduled procedure?
Correct Answer: B
Rationale: In this scenario, option B is the correct answer that warrants notification of the healthcare provider before proceeding with the scheduled procedure. A blood pressure reading of 184/88 mm Hg indicates hypertension, which can increase the risk of intraoperative and postoperative complications, such as bleeding and cardiac events. Option A, light yellow coloring of the skin and eyes, could indicate jaundice, which may also be concerning but is not as immediately life-threatening as uncontrolled hypertension. Option C, vomiting clear yellowish fluid, may suggest bile reflux, but it is not as urgent or critical as uncontrolled hypertension. Option D, a red, swollen, and leaking IV insertion site, indicates a local infection or infiltration, which is important but can be addressed by the nursing staff without delaying the procedure. Educationally, this question highlights the importance of recognizing and prioritizing critical assessment findings in the preoperative setting, emphasizing the impact of vital signs on surgical outcomes in pediatric patients undergoing general anesthesia. Nurses must be vigilant in identifying potential risk factors to ensure patient safety and optimal surgical outcomes.
Question 5 of 5
A female client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that her distal pulses are diminished in the left foot. Which interventions should the nurse implement? (Select all that apply.)
Correct Answer: B
Rationale: In this scenario, the correct answer is option B: Verify pedal pulses using a doppler pulse device. Explanation: When a client has a fractured femur and is immobilized with a traction splint, there is a risk of compromised circulation to the extremity, which can lead to vascular compromise or compartment syndrome. Checking pedal pulses using a doppler pulse device is crucial to assess perfusion distal to the fracture site. Diminished pulses could indicate impaired blood flow, requiring immediate intervention to prevent further complications. Why the other options are incorrect: A) Offering ice chips and oral clear liquids is not relevant to assessing distal pulses in this situation. C) While monitoring for pain, pallor, paresthesia, paralysis, and pressure is important, directly assessing pulses is more specific to evaluating perfusion. D) Evaluating the application of the splint is important but does not directly address the immediate concern of diminished distal pulses. Educational context: This question highlights the significance of vascular assessment in clients with fractures and immobilization devices. Nurses must be vigilant in monitoring circulation to prevent complications such as impaired tissue perfusion. Understanding the rationale behind assessing distal pulses in such cases is crucial for providing safe and effective care to pediatric clients with orthopedic injuries.