ATI LPN
Immune System Practice Questions Questions
Question 1 of 5
A client with disseminated intravascular coagulation (DIC) has a nursing diagnosis of Impaired Gas Exchange. Which action is inappropriate when providing care based on this nursing diagnosis?
Correct Answer: A
Rationale: Correct answer: A. Placing the client in a low-Fowler position is inappropriate because it can worsen gas exchange in a client with DIC. Rationale: 1. In DIC, impaired gas exchange is often due to microthrombi formation in the lungs, leading to ventilation-perfusion mismatch. 2. Placing the client in a low-Fowler position can further compromise ventilation by decreasing lung expansion and worsening perfusion. 3. Monitoring oxygen saturation continuously (B) is essential in assessing gas exchange status. 4. Maintaining bed rest (C) helps reduce oxygen demand and prevent complications from movement. 5. Encouraging deep breathing and coughing (D) can help maintain lung expansion and prevent atelectasis. In summary, placing the client in a low-Fowler position is inappropriate as it can worsen gas exchange, while monitoring oxygen saturation, maintaining bed rest, and promoting deep breathing and coughing are appropriate interventions for a client with DIC and impaired gas exchange.
Question 2 of 5
A nurse enters the room of a teenager after the physician has obtained informed consent for a voiding cystourethrogram. The teenager asks the nurse to explain the procedure again. The nurse tells the client that the client is asked to void after:
Correct Answer: C
Rationale: The correct answer is C: Injection of contrast dye into the bladder via a catheter. In a voiding cystourethrogram, contrast dye is indeed injected into the bladder via a catheter to visualize the urinary tract during voiding. This allows for the assessment of bladder and urethra function. Choices A and D are incorrect because radioisotopes are not typically used in this procedure. Choice B is incorrect as contrast dye is not injected into the bloodstream but rather directly into the bladder. Therefore, the correct answer is C as it accurately describes the procedure for a voiding cystourethrogram.
Question 3 of 5
A nurse is assisting with the admission of a toddler who has nephrotic syndrome. Which of the following objective data should the nurse anticipate collecting from the child?
Correct Answer: A
Rationale: The correct answer is A: Elevated blood pressure. In nephrotic syndrome, there is a loss of protein in the urine, leading to hypoalbuminemia and fluid retention, which can result in elevated blood pressure. This is due to the body's attempt to maintain fluid balance. Option B is incorrect because in nephrotic syndrome, serum cholesterol and fat levels are typically elevated, not lower than normal. Option C is incorrect as 3+ to 4+ protein in the urine is indicative of proteinuria, a common finding in nephrotic syndrome. Option D is incorrect as thin limbs with loose skin are not typically associated with nephrotic syndrome.
Question 4 of 5
The nurse admitting and assessing a teenage boy with suspected testicular torsion (twisted testicle) will most likely find which of the following manifestations in addition to possible nausea and vomiting and acute testicular pain?
Correct Answer: B
Rationale: The correct answer is B: Cremasteric reflex depressed or absent. Testicular torsion causes twisting of the spermatic cord, cutting off blood supply to the testicle, leading to severe pain, nausea, and vomiting. The cremasteric reflex, which causes the testicle to elevate when the inner thigh is stroked, is typically absent in cases of testicular torsion due to the severe pain and ischemia. Choices A, C, and D are incorrect as relief of pain with elevation of the testicle, pain or discomfort upon urination, and presence of white blood cells and bacteria in the urine are not typical manifestations of testicular torsion.
Question 5 of 5
A school-age client is recovering after abdominal surgery. The nurse is planning care for the return of bowel function. Which intervention should be included in the client’s plan of care?
Correct Answer: D
Rationale: The correct answer is D - Ambulate 3-4 times a day. Ambulation helps stimulate peristalsis and aids in the return of bowel function after abdominal surgery. Walking promotes movement in the abdomen, preventing complications like ileus. Fowler's position (choice A) may help with breathing but does not directly impact bowel function. Choosing a low-fat diet (choice B) is important for overall health but does not directly promote bowel function. Having a commode at the bedside (choice C) is convenient but does not actively facilitate the return of bowel function like ambulation does.