ATI RN
Pediatric Cardiovascular Disorders Nursing Questions
Question 1 of 5
A client with acquired immunodeficiency syndrome (AIDS) has impaired gas exchange from a respiratory infection. Which assessment finding warrants immediate intervention by the nurse?
Correct Answer: D
Rationale: In this scenario, the correct answer is D) Pain when swallowing, which warrants immediate intervention by the nurse. The rationale for this choice is that pain when swallowing can indicate potential complications such as esophagitis or opportunistic infections like candidiasis, which are common in individuals with AIDS. These conditions can further compromise the client's respiratory status and lead to serious complications, making it crucial for the nurse to address this symptom promptly to prevent further deterioration in gas exchange. Option A) Elevated temperature is a common sign of infection, which is important to monitor but may not directly impact gas exchange as urgently as pain when swallowing in this context. Option B) Generalized weakness is a non-specific symptom that may be seen in various conditions and does not directly address the immediate respiratory concerns. Option C) Diminished lung sounds could indicate respiratory compromise, but given the client's specific condition of impaired gas exchange from a respiratory infection, the symptom of pain when swallowing takes precedence in terms of urgency for intervention. In an educational context, understanding the priority of symptoms and assessments in clients with complex conditions like AIDS is crucial for nurses caring for these individuals. Recognizing the significance of certain symptoms over others based on their potential impact on the client's health is a key aspect of providing effective and timely nursing care in such cases. By prioritizing interventions based on the client's specific needs and condition, nurses can optimize patient outcomes and ensure high-quality care delivery.
Question 2 of 5
The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. What action should the nurse take?
Correct Answer: A
Rationale: In this scenario, the correct action for the nurse to take is Option A) Collect the blood sample. The reddened and engorged appearance of the distal tip of the finger after milking can be indicative of capillary refill, a sign that the circulation to the area is good. This means that the blood flow is adequate to obtain a reliable capillary blood sample for glucose testing. Option B) Assess radial pulse volume is incorrect because the appearance of the finger after milking does not necessarily correlate with the radial pulse volume. The focus here is on obtaining a blood sample for glucose testing, not on assessing pulse volume. Option C) Apply pressure to the site is incorrect as applying pressure can alter the blood flow to the area and potentially affect the accuracy of the glucose reading. Option D) Select another finger is also incorrect as the appearance of the finger is not a contraindication for collecting the blood sample. Educationally, this question highlights the importance of understanding the significance of capillary refill in relation to obtaining blood samples for testing. It reinforces the need for nurses to recognize normal physiological responses in pediatric clients and how these responses can impact nursing interventions. This knowledge is crucial in ensuring accurate assessments and appropriate care for pediatric patients.
Question 3 of 5
A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client's postoperative discharge instructions?
Correct Answer: D
Rationale: In the context of a client with urolithiasis post-lithotripsy, the correct intervention to include in postoperative discharge instructions is option D) Give IV dose of adenosine rapidly over 1-2 seconds. Adenosine is commonly used to treat supraventricular tachycardia, a condition that can occur as a complication of lithotripsy due to the stress and pain associated with the procedure. Rapid administration of adenosine can help restore normal sinus rhythm by temporarily blocking conduction through the atrioventricular node. Option A) Prepare for transcutaneous pacing is incorrect as it is not indicated in this situation. Transcutaneous pacing is used for bradycardia or heart blocks, not for supraventricular tachycardia. Option B) Deliver another defibrillator shock is also incorrect. Defibrillation is used for life-threatening arrhythmias like ventricular fibrillation or ventricular tachycardia, not for supraventricular tachycardia. Option C) Administer IV Epinephrine per ACLS protocol is not the correct choice either. Epinephrine is typically used in cardiac arrest situations to improve myocardial and cerebral perfusion, not for treating supraventricular tachycardia post-lithotripsy. Educationally, understanding the appropriate pharmacological interventions post-lithotripsy is crucial for nurses caring for patients with urolithiasis. It is important to differentiate between different types of arrhythmias and their respective treatments to provide safe and effective care to patients recovering from procedures like lithotripsy.
Question 4 of 5
During preoperative teaching for a male client scheduled for repair of an inguinal hernia, the client tells the nurse that he has had several surgeries and understands the need to perform coughing and deep breathing exercises after surgery. How should the nurse respond?
Correct Answer: A
Rationale: The correct answer is A) Ask for a demonstration of these exercises. This response is appropriate because it allows the nurse to assess the client's understanding of the coughing and deep breathing exercises. By asking for a demonstration, the nurse can ensure that the client is performing the exercises correctly, which is crucial for preventing postoperative complications such as atelectasis and pneumonia. Option B) Explain that coughing should be avoided is incorrect as coughing and deep breathing exercises are actually encouraged after surgery to promote lung expansion, improve oxygenation, and prevent respiratory complications. Option C) Review the client’s previous surgical history is not the most appropriate response in this situation as the client has already mentioned understanding the need for coughing and deep breathing exercises. Focusing on the current teaching and assessment of understanding is more relevant. Option D) Document the client's understanding of teaching is important but not sufficient on its own. While documentation is crucial, it does not actively assess the client's ability to perform the exercises correctly. In an educational context, this scenario highlights the importance of active assessment and validation of patient understanding in the teaching process. By asking for a demonstration, nurses can ensure that patients have the necessary skills and knowledge to care for themselves effectively postoperatively.
Question 5 of 5
A nurse assists a male client with Parkinson's disease (PD) to ambulate in the hallway. The client appears to 'freeze' and then carefully lifts one leg and steps forward. He tells the nurse that he is pretending to step over a crack on the floor. How should the nurse respond?
Correct Answer: B
Rationale: In this scenario, option B is the correct response. The client with Parkinson's disease is exhibiting a phenomenon known as "freezing of gait," a common symptom in PD where individuals feel as though their feet are glued to the floor and have difficulty initiating movement. By pretending to step over a crack, the client is using a technique called "cued stepping," which can help overcome freezing episodes and facilitate ambulation. Option A is incorrect as re-orienting the client is not addressing the immediate issue of freezing of gait. Option C is also incorrect as simply changing the surface to carpeted area may not address the underlying problem and may not be practical in all settings. Option D is incorrect as assessing cognition is not the priority at this moment when the client is experiencing a physical symptom related to PD. Educationally, it is important for nurses to understand the various manifestations of Parkinson's disease, including freezing of gait, and how to effectively manage these symptoms to support the client in their activities of daily living. Understanding and recognizing cues like pretending to step over a crack can be crucial in providing holistic care for clients with PD.