ATI RN
Burns Pediatric Primary Care 7th Edition Test Bank Questions
Question 1 of 5
A client receives a sealed radiation implant to treat cervical cancer. When caring for this client, the nurse should:
Correct Answer: B
Rationale: When caring for a client who has received a sealed radiation implant to treat cancer, it is important to consider the client to be radioactive for a certain period of time. Typically, the client is considered radioactive for about 10 days after the implant is removed. During this time, precautions should be taken to limit exposure to radiation, including following the principles of time, distance, and shielding. It is important for healthcare providers to wear appropriate protective gear when caring for the client and to limit the time spent in close proximity to the client. After the radioactive period has passed, the client will no longer be considered radioactive, and standard precautions can be followed.
Question 2 of 5
Pulmonary edema is characterized by:
Correct Answer: C
Rationale: Pulmonary edema is characterized by increased hydrostatic pressure in the pulmonary capillaries and a rise in pulmonary venous pressure, which leads to fluid leaking out of the pulmonary capillaries and into the alveoli. This results in elevated left ventricular end-diastolic pressure, which is a key characteristic of pulmonary edema. Therefore, all of the above alterations (increased hydrostatic pressure, a rise in pulmonary venous pressure, and elevated left ventricular end-diastolic pressure) are seen in pulmonary edema.
Question 3 of 5
When caring for an anxious patient with dyspnea, which of the ff. nursing actions is most helpful to include in the plan of care to relieve anxiety?
Correct Answer: C
Rationale: One of the most helpful nursing actions to include in the plan of care to relieve anxiety in an anxious patient with dyspnea is to stay at the patient's bedside. By providing constant presence and reassurance, the nurse can help the patient feel supported and safe. This proactive approach can also help the nurse monitor the patient's condition closely and provide timely interventions as needed. Additionally, staying at the bedside allows the nurse to establish trust and communication with the patient, which is essential in managing anxiety and providing effective care.
Question 4 of 5
The nurse understands that which of the ff. is a side effect most likely to be reported by patients receiving enalapril maleate (Vasotec)?
Correct Answer: C
Rationale: The most common side effect reported by patients receiving enalapril maleate (Vasotec) is a persistent dry cough. This cough is due to the medication's effect on bradykinin levels in the body, leading to irritation of the respiratory tract and causing the cough. While other side effects such as diarrhea and heartburn may occur, cough is the most frequently reported side effect associated with enalapril maleate. Acne is not a commonly reported side effect of this medication.
Question 5 of 5
Which of the following BP changes alerts the nurse to increasing ICP, and should be reported immediately?
Correct Answer: B
Rationale: Widening pulse pressure is indicative of increasing intracranial pressure (ICP) and must be reported immediately. Pulse pressure is calculated by subtracting the diastolic blood pressure from the systolic blood pressure. An increasing pulse pressure can suggest a rise in ICP due to factors like cerebral edema or hemorrhage. This change indicates increased pressure exerted on blood vessels within the brain, potentially leading to serious consequences like brain herniation. Thus, recognizing and promptly reporting a widening pulse pressure is crucial to prevent further complications and enable appropriate interventions for the patient.