ATI RN
Pediatric Cardiovascular Disorders Nursing Questions
Question 1 of 5
A client tells the nurse that her biopsy results indicate that the cancer cells are well-differentiated. How should the nurse respond?
Correct Answer: A
Rationale: Rationale: The correct answer is A) Ask the client if the healthcare provider has given her any information about the classification of her cancer. Explanation: 1. Option A is correct because it demonstrates therapeutic communication by encouraging the client to seek clarification from her healthcare provider. This empowers the client to better understand her condition and treatment options. 2. Option B is incorrect because stating that well-differentiated cancer cells usually have a poor prognosis is inaccurate. Well-differentiated cells are more similar to normal cells and may indicate a less aggressive cancer type. 3. Option C is incorrect as it provides false reassurance. All cancer diagnoses should be taken seriously, and it is essential to provide accurate information and support to the client. 4. Option D is incorrect because encouraging the client to seek a second opinion without clarifying the information provided by the healthcare provider may lead to confusion and delay in necessary treatment. Educational Context: Understanding cancer cell differentiation is crucial in determining the aggressiveness and prognosis of cancer. Well-differentiated cells resemble normal cells and may indicate a less aggressive cancer type compared to poorly differentiated cells. As a nurse, it is important to facilitate open communication, provide accurate information, and support clients in seeking clarification from their healthcare providers to make informed decisions about their care.
Question 2 of 5
A nurse is caring for a client with Diabetes Insipidus (DI). Which data warrants the most immediate intervention by the nurse?
Correct Answer: A
Rationale: In the context of caring for a client with Diabetes Insipidus (DI), the most immediate intervention by the nurse is warranted by option A) Serum sodium of 185 mEq/L. This elevated serum sodium level indicates hypernatremia, which can be life-threatening in DI due to excessive water loss. Hypernatremia can lead to neurological symptoms like confusion, seizures, and coma, requiring urgent correction to prevent serious complications like brain damage. Option B) Urine output of 3000 mL per hour is a common manifestation of DI but does not pose an immediate threat as hypernatremia does. Monitoring and managing fluid balance are crucial, but the urgency lies in correcting the electrolyte imbalance first. Option C) Blood pressure of 90/60 mmHg is low but not as immediately critical as managing the electrolyte imbalance. It may be related to dehydration from DI but can be addressed once the serum sodium is stabilized. Option D) Potassium level of 4.5 mEq/L is within the normal range and is not an immediate concern in this scenario. While potassium balance is important, addressing hypernatremia takes precedence. Educationally, understanding the prioritization of interventions based on the urgency of the client's condition is crucial in nursing practice. This scenario highlights the need for nurses to recognize and respond promptly to critical electrolyte imbalances to prevent serious complications and ensure client safety.
Question 3 of 5
In assessing a client with ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin?
Correct Answer: B
Rationale: In assessing a client with ulcers on the lower extremity, findings that indicate venous ulcers over arterial ulcers are irregular ulcer shapes and severe edema. Venous ulcers tend to have irregular shapes due to the underlying venous hypertension, while arterial ulcers are typically more uniform in shape. Severe edema is also more characteristic of venous insufficiency, as impaired venous return leads to fluid accumulation in the tissues. Option A, black ulcers and dependent rubor, are more indicative of arterial ulcers. Black ulcers suggest ischemia and necrosis, while dependent rubor is a sign of arterial insufficiency. Option C, absent pedal pulses and shiny skin, are also more indicative of arterial ulcers, as impaired arterial blood flow leads to diminished pulses and shiny, atrophic skin. Option D, hairless lower extremities and cool feet, can be seen in both arterial and venous insufficiency, but are not as specific to venous ulcers as irregular ulcer shapes and severe edema. Educationally, understanding the differences in presentation between venous and arterial ulcers is crucial for nurses caring for patients with cardiovascular disorders. Recognizing these differences can guide appropriate interventions and help prevent complications associated with mismanagement of these conditions.
Question 4 of 5
An older male client with long-standing lung disease is admitted to the medical unit for treatment of pulmonary infection. In assessing for signs of increasing hypoxia, which action should the nurse include? (select all that apply)
Correct Answer: B
Rationale: In this scenario, the correct action the nurse should include in assessing for signs of increasing hypoxia in an older male client with long-standing lung disease is to check for changes in mentation (Option B). This is because changes in mentation, such as confusion or altered level of consciousness, can be early indicators of worsening hypoxia in patients with lung disease. Monitoring dryness of mucous membranes (Option A) is not a reliable indicator of hypoxia in this case because it is more specific to hydration status rather than oxygenation. Observing the color of skin and nailbeds (Option C) is important for assessing oxygenation, but it is a later sign of hypoxia. Noting the appearance of jugular veins (Option D) is not directly related to assessing hypoxia in this context. Educationally, it is important for nurses to understand the various signs and symptoms of hypoxia in patients with respiratory conditions, as early recognition and intervention are crucial in preventing adverse outcomes. Checking for changes in mentation can provide valuable information about the client's oxygenation status and help guide appropriate nursing interventions.
Question 5 of 5
The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for administration of digoxin (Lanoxin). Which statement by the parent indicates a need for further instruction?
Correct Answer: A
Rationale: The correct answer is A) “If my child vomits after the medication administration, I will repeat the dose.” Rationale: A) This statement indicates a need for further instruction because if a child vomits after taking digoxin, repeating the dose can lead to overdosing, which can be harmful. It is crucial for parents to understand not to double dose without healthcare provider guidance. B) Mixing digoxin with food can alter its absorption, so it is correct not to mix it with food. C) Taking the child’s pulse before administering digoxin is essential as it helps monitor for signs of digoxin toxicity, so this statement is correct. D) Contacting the healthcare provider if more than one dose is missed is crucial to ensure proper management of the child's condition, making this statement correct. Educational Context: Parents need clear instructions on administering medications like digoxin to avoid potential harm. Understanding the importance of proper dosing, monitoring for side effects, and when to seek medical advice is crucial in managing pediatric cardiovascular disorders effectively. Reinforcing these key points can help parents confidently care for their child at home.