ATI RN
Maternity and Pediatric Nursing 4th Edition Test Bank Questions
Question 1 of 5
A client is in isolation after receiving an internal radioactive implant to treat cancer. Two hours later, the nurse discovers the implant in the bed linens. What should the nurse do first?
Correct Answer: B
Rationale: The nurse should first pick up the internal radioactive implant with long-handled forceps and place it in a lead-lined container. This action ensures the safety of the nurse and prevents further exposure to radiation. Handling the implant with forceps helps minimize direct contact, and placing it in a lead-lined container containing the radiation will effectively shield any further exposure. Once the implant is secured, proper authorities should be notified to take further action and ensure the client's safety.
Question 2 of 5
The mother of a preterm newborn asks the nurse when she can start breastfeeding. The nurse should explain that breastfeeding can be initiated when her newborn:
Correct Answer: D
Rationale: Breastfeeding can be initiated when the newborn has adequate sucking and swallowing reflexes, which usually develop around 34 to 36 weeks gestational age. It is important for the newborn to have the ability to latch onto the breast and suck effectively in order to receive adequate nutrition and establish a good breastfeeding relationship with the mother. Indicating an interest in breastfeeding is important as well, but having the reflexes necessary for successful breastfeeding is a key factor in determining readiness to begin breastfeeding.
Question 3 of 5
During the physical examination of a client for a possible neurologic disorder, how can the nurse examine the client for stiffness and rigidity of the neck?
Correct Answer: B
Rationale: The nurse can examine the client for stiffness and rigidity of the neck by moving the head and chin of the client toward the chest. This maneuver, known as neck flexion, assesses the resistance and presence of stiffness in the neck muscles. Stiffness and rigidity of the neck muscles may suggest conditions such as meningitis, cervical dystonia, or other neurologic disorders. It is important for the nurse to perform this examination maneuver carefully to avoid causing discomfort or injury to the client.
Question 4 of 5
A client on hemodialysis is complaining of muscle weakness and numbness in his legs. His lab results are: Na 136 mEq/L, K 5.9 mEq/L, Cl 100 mEq/L, ca 8.5 mg/dl. Which electrolyte imbalance is the client suffering from?
Correct Answer: A
Rationale: The client is experiencing muscle weakness and numbness in his legs, which are symptoms commonly associated with hyperkalemia (high potassium levels). The potassium level of 5.9 mEq/L is above the normal range (3.5-5.0 mEq/L), indicating hyperkalemia. Hyperkalemia can lead to muscle weakness, numbness, and potentially more severe complications like cardiac arrhythmias.
Question 5 of 5
Which of the following dietary interventions prevents the precipitation of calcium renal stones?
Correct Answer: C
Rationale: High fluid intake is the dietary intervention that prevents the precipitation of calcium renal stones. By increasing fluid intake, particularly water, the urine gets diluted, thus reducing the concentration of substances that can lead to the formation of kidney stones, including calcium. Drinking enough water can also help to flush out any potential stone-forming minerals or substances before they have a chance to crystallize and form stones in the kidney. It is recommended to have an adequate fluid intake of around 2 to 3 liters per day to reduce the risk of calcium stone formation in the kidneys. High fiber diet, increased protein intake, and intake of zinc do not directly prevent the precipitation of calcium renal stones as effectively as maintaining high fluid intake.