ATI RN
Pediatric Nursing Cardiovascular NCLEX Practice Quiz Questions
Question 1 of 5
A client who had a biliopancreatic diversion procedure (BDP) 3 months ago is admitted with severe dehydration. Which assessment finding warrants immediate intervention by the nurse?
Correct Answer: B
Rationale: In this scenario, option B, "Gastroccult positive emesis," warrants immediate intervention by the nurse. This finding indicates the presence of blood in the vomitus, which could be a sign of gastrointestinal bleeding, a serious complication after a biliopancreatic diversion procedure. Prompt assessment and intervention are crucial to prevent further complications such as hypovolemic shock. Option A, "Strong foul-smelling flatus," is a common occurrence post-BDP due to changes in digestion but does not require immediate intervention as it is not indicative of a life-threatening condition. Option C, "Complaint of poor night vision," is unrelated to the client's current presentation of severe dehydration and is more likely associated with vitamin deficiencies common in patients post-BDP, but it does not require immediate intervention. Option D, "Loose bowel movements," can be expected after a BDP as a side effect of the procedure and dehydration but does not pose an immediate threat to the client's life. Educationally, this question highlights the importance of recognizing and prioritizing assessment findings that indicate potential life-threatening complications in patients with specific surgical histories. Understanding the postoperative complications of biliopancreatic diversion procedures and their associated signs and symptoms is crucial for nurses caring for these patients.
Question 2 of 5
A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 1 to 10 scale. Which intervention should the nurse implement?
Correct Answer: A
Rationale: In this scenario, the correct intervention is to administer opioid and non-opioid medication simultaneously (Option A). This approach is appropriate for managing severe pain effectively in a client with stage IV bone cancer. Opioids provide potent pain relief, while non-opioid medications such as NSAIDs or acetaminophen can complement their effects and improve overall pain management without solely relying on opioids, which may have limitations in severe cases. Option B, administering only opioid medication, may not provide adequate pain relief for severe pain, especially in a case like stage IV bone cancer where pain can be excruciating. Option C, encouraging relaxation techniques, is not sufficient to address severe pain in this context and may delay appropriate pain management. Option D, delaying medication administration until reassessment, is inappropriate as immediate pain relief is crucial for the client's well-being and comfort. Educationally, it is important for nurses to understand the principles of multimodal pain management, especially in cases of severe pain like in advanced cancer. By combining opioids with non-opioid medications, healthcare providers can optimize pain relief while minimizing potential opioid-related side effects, thus improving the overall quality of care for patients in pain.
Question 3 of 5
When explaining dietary guidelines to a client with acute glomerulonephritis (AGN), which instruction should the nurse include in the dietary teaching?
Correct Answer: A
Rationale: In the context of a client with acute glomerulonephritis (AGN), the nurse should include the instruction to restrict sodium intake in the dietary guidelines. Sodium restriction is crucial in managing AGN because excessive sodium can lead to fluid retention and hypertension, which can further damage the already compromised kidneys in AGN. By limiting sodium intake, the client can help reduce fluid retention and manage blood pressure, thus supporting kidney function. Encouraging high-protein foods (option B) is not appropriate in AGN because excessive protein intake can increase the workload on the kidneys, potentially worsening the condition. Similarly, increasing potassium intake (option C) is not advisable as impaired kidney function in AGN can lead to hyperkalemia, making it important to monitor and potentially restrict potassium intake. Decreasing fluid intake (option D) may be necessary in some cases of AGN to manage fluid overload, but it is not the primary dietary guideline for this condition. In AGN, sodium restriction takes precedence over fluid restriction as excess sodium can contribute to fluid retention and hypertension, both of which can worsen kidney function. In an educational context, understanding the rationale behind dietary guidelines in specific conditions like AGN is crucial for nurses to provide effective patient care. By explaining the reasons behind dietary recommendations, nurses can empower clients to actively participate in their care and make informed choices to support their health outcomes.
Question 4 of 5
The nurse is providing discharge instructions to a client who is receiving prednisone (Deltasone) 5 mg PO daily for a rash due to contact with poison ivy. Which symptom should the nurse tell the client to report to the healthcare provider?
Correct Answer: A
Rationale: In this scenario, the correct answer is A) Rapid weight gain. Prednisone, a corticosteroid, can cause fluid retention and sodium retention in the body, leading to weight gain. Rapid weight gain may indicate fluid overload, a serious side effect that needs immediate medical attention to prevent complications such as heart failure or edema. Option B) Increased energy levels is incorrect because prednisone typically causes side effects such as insomnia, mood changes, or nervousness, but not necessarily increased energy levels. Option C) Frequent headaches are not a common side effect of prednisone and would not be a priority symptom to report. Option D) Dry mouth is a common side effect of prednisone, but it is usually not a serious symptom that requires immediate medical attention. Educationally, this question emphasizes the importance of understanding the side effects of medications commonly prescribed in pediatric patients, the significance of monitoring for adverse reactions, and the need for clear patient education to ensure timely reporting of concerning symptoms to healthcare providers. Nurses need to be vigilant in educating patients and caregivers about potential side effects of medications, especially in pediatric populations where monitoring for adverse reactions is crucial.
Question 5 of 5
The nurse is monitoring an infant with a congenital heart disease closely for signs of heart failure. Which early sign should the nurse be most concerned about?
Correct Answer: C
Rationale: In pediatric nursing, understanding the early signs of heart failure in infants with congenital heart disease is crucial for timely intervention. In this scenario, the correct answer is C) Tachycardia. Tachycardia, an elevated heart rate, is a significant early sign of heart failure in infants. It indicates the heart's inability to meet the body's oxygen demands, leading to compensatory mechanisms like increased heart rate. Option A) Pallor is a non-specific sign that can occur in various conditions and may not specifically indicate heart failure in this context. Option B) Cough is more commonly associated with respiratory issues rather than early signs of heart failure. Option D) Slow and shallow breathing can be a late sign of heart failure, whereas tachycardia is an earlier indicator. Educationally, understanding these nuanced differences is crucial for nurses caring for pediatric patients with cardiac conditions. Recognizing early signs of deterioration can prompt swift interventions, potentially preventing adverse outcomes. Nurses must be vigilant in monitoring these subtle changes in infants to provide timely and effective care.