ATI RN
Pediatric Cardiovascular Nursing Questions Questions
Question 1 of 5
A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare provider.
Correct Answer: C
Rationale: In this scenario, the correct answer is C) Yellow sclera. Yellow sclera is indicative of jaundice, a common manifestation of common bile duct obstruction. When the common bile duct is obstructed by a gallstone, bilirubin cannot be excreted properly, leading to jaundice. This finding is significant as it suggests a worsening condition that requires prompt medical attention to prevent further complications. Belching (option A) and flatulence (option D) are common gastrointestinal symptoms that may occur due to various reasons, including dietary factors or digestive issues. These symptoms, while uncomfortable, are not specific indicators of a common bile duct obstruction in this context. Amber urine (option B) can be a normal finding and may indicate dehydration rather than a direct consequence of the common bile duct obstruction. It is not a primary concern in this situation where the focus should be on identifying signs of worsening obstruction. In an educational context, understanding the clinical manifestations of common bile duct obstruction in patients with cholelithiasis is crucial for nurses caring for such patients. Recognizing these signs early can help in timely intervention and prevention of complications. Nurses must be able to prioritize and report significant findings to healthcare providers promptly to ensure appropriate management and patient safety.
Question 2 of 5
A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vital signs are temperature 101F, heart rate 128 beats/minute, respirations 28 breaths/minute, and blood pressure 122/82. Which intervention is most important for the nurse to implement first?
Correct Answer: D
Rationale: The most important intervention for the nurse to implement first in this scenario is option D, to administer a PRN oral antipyretic. The client presenting with a right hip fracture and exhibiting signs of infection (elevated temperature of 101F) requires immediate attention to manage the fever, which can be indicative of a systemic response to infection. Administering an antipyretic will help lower the fever and alleviate the client's discomfort. Option A, obtaining oxygen saturation, is not the priority in this case as the client's respiratory status is not the primary concern. The diminished breath sounds may be related to the underlying condition, and addressing the fever takes precedence. Option B, encouraging incentive spirometry, is important for preventing respiratory complications in clients with limited mobility but is not the most urgent intervention in this situation. Option C, assessing lower extremity circulation, although important for a client with a right hip fracture, is not the priority when the client is exhibiting signs of infection and an elevated temperature. In an educational context, it is crucial for nurses to prioritize interventions based on the client's immediate needs and clinical presentation. Understanding the rationale behind each option helps nurses make informed decisions to provide timely and effective care to their patients.
Question 3 of 5
When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain?
Correct Answer: A
Rationale: In caring for a client with nephrotic syndrome, obtaining a daily weight is the most important assessment for the nurse to perform. Nephrotic syndrome is characterized by massive protein loss leading to edema, particularly in the abdominal area. Daily weight monitoring is crucial as it reflects fluid retention or loss, which can indicate disease progression or response to treatment. Changes in weight help guide medication dosages, fluid restriction, and dietary adjustments. Vital signs are important in assessing overall health but may not provide specific information related to fluid status in nephrotic syndrome. Level of consciousness is more relevant in neurological conditions, not directly related to nephrotic syndrome. Bowel sounds are not the priority in this case unless there are specific gastrointestinal symptoms present, which are not typically associated with nephrotic syndrome. Educationally, understanding the rationale behind the importance of daily weight monitoring in nephrotic syndrome highlights the link between pathophysiology and nursing assessment. It reinforces the significance of regular assessments in providing optimal care for pediatric patients with complex conditions.
Question 4 of 5
A client with cancer is receiving chemotherapy with a known vesicant. The client's IV has been in place for 72 hours. The nurse determines that a new IV site cannot be obtained, and leaves the present IV in place. What is the greatest clinical risk related to this situation?
Correct Answer: A
Rationale: In the scenario presented, the correct answer is A) Impaired skin integrity. When a vesicant medication, such as chemotherapy, leaks into the surrounding tissues due to a poorly functioning or long-standing IV site, it can cause severe damage to the skin, subcutaneous tissues, and even lead to necrosis. This poses a significant risk to the patient's health and can result in long-term complications. Option B) Fluid volume excess is not directly related to the situation described. Option C) Acute pain and anxiety may occur but are not the greatest risk compared to the potential tissue damage caused by the vesicant. Option D) Peripheral neurovascular dysfunction is also not the primary concern in this context. Educationally, understanding the importance of maintaining IV sites properly in patients receiving vesicant medications is crucial for nurses caring for oncology patients. It highlights the significance of timely assessment, intervention, and advocating for the safe administration of medications to prevent serious complications and promote patient well-being.
Question 5 of 5
While planning care for a client with carpal tunnel syndrome, the nurse identifies a collaborative problem of pain. what is the etiology of this problem?
Correct Answer: D
Rationale: In the context of a client with carpal tunnel syndrome experiencing pain as a collaborative problem, the correct etiology is identified as "Compression of a nerve" (Option D). Carpal tunnel syndrome involves the compression of the median nerve as it passes through the carpal tunnel in the wrist. This compression leads to symptoms such as pain, numbness, and tingling in the affected hand and fingers. Explanation of why the other options are incorrect: A) Irritation of nerve endings: While irritation of nerve endings can contribute to pain, in carpal tunnel syndrome, the primary issue is nerve compression rather than just irritation. B) Diminished blood flow: Diminished blood flow may lead to tissue ischemia but is not the primary cause of pain in carpal tunnel syndrome. C) Ischemic tissue changes: Ischemic tissue changes may occur if there is prolonged compression leading to nerve damage, but this is not the immediate etiology of pain in carpal tunnel syndrome. Educational context: Understanding the etiology of pain in carpal tunnel syndrome is crucial for nurses caring for pediatric clients with this condition. By recognizing that pain arises from nerve compression within the carpal tunnel, nurses can implement appropriate interventions to alleviate pain, such as splinting, ergonomic modifications, and possibly surgical intervention in severe cases. Educating patients and families about the importance of managing this compression can help improve outcomes and quality of life for pediatric clients with carpal tunnel syndrome.