ATI RN
Pediatric Cardiovascular Disorders Nursing Questions
Question 1 of 5
A healthcare worker with no known exposure to tuberculosis has received a Mantoux tuberculosis skin test. The nurse's assessment of the test after 62 hours indicates 5 mm of erythema without induration. What is the best initial nursing action?
Correct Answer: A
Rationale: The best initial nursing action in this scenario is to choose option A) Document negative results in the client's medical record. This is the correct choice because a Mantoux tuberculosis skin test showing 5 mm of erythema without induration after 62 hours is considered negative for tuberculosis infection. It is crucial for healthcare workers to have accurate documentation of test results in the medical record to ensure proper monitoring and follow-up. Option B) Repeat the test immediately on the opposite forearm is not necessary in this case as the initial test result is already negative. Repeating the test without a valid reason can lead to unnecessary discomfort for the healthcare worker and is not supported by evidence-based practice. Option C) Notify the healthcare provider for further evaluation is also not warranted in this situation as the test result is negative. Contacting the healthcare provider without a valid reason can lead to unnecessary burden on the provider and may result in inappropriate follow-up procedures. Option D) Schedule the worker for a chest X-ray is not indicated based on the negative Mantoux test result. Chest X-rays are typically ordered when there are signs and symptoms suggestive of active tuberculosis, which is not the case here. In an educational context, understanding the interpretation of diagnostic tests like the Mantoux test is crucial for nurses working in various clinical settings. It is essential for nurses to be able to accurately interpret test results, document findings appropriately, and follow evidence-based guidelines to provide optimal care for their patients.
Question 2 of 5
A male client in skeletal traction tells the nurse that he is frustrated because he needs help repositioning himself in bed. Which intervention should the nurse implement?
Correct Answer: A
Rationale: In this scenario, the correct intervention is option A, which is to provide an overhead trapeze to the bed for the client to use. This is the most appropriate intervention because it empowers the client to reposition himself independently, promoting autonomy and preserving his dignity. Option B, assisting the client with repositioning every hour, may not be feasible due to staffing constraints and may not address the client's frustration with needing constant assistance. Option C, encouraging the use of a bedpan, does not address the client's need for repositioning and mobility, which are important for preventing complications associated with immobility. Option D, offering additional pain medication, does not address the client's need for repositioning and may not be the most appropriate solution for his frustration with his limited mobility. Educationally, it is important for nurses to promote independence and autonomy in patients whenever possible, especially in situations where the client's frustration with limited mobility needs to be addressed. Providing assistive devices like an overhead trapeze not only helps the client physically but also psychologically by giving him a sense of control over his own care.
Question 3 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 4 of 5
A male client complains of pain in his right calf, and the nurse determines that his calf is edematous and deep red. What intervention has the highest priority?
Correct Answer: A
Rationale: The highest priority intervention in this scenario is option A) Tell the client to remain in bed. This presentation of pain, edema, and redness in the calf is indicative of a potential deep vein thrombosis (DVT). By advising the client to stay in bed, we aim to limit movement that could dislodge a blood clot, potentially causing a pulmonary embolism. This intervention is crucial to prevent a life-threatening complication. Option B) Apply warm compresses is not recommended in this case as heat can increase blood flow and potentially dislodge a clot, leading to adverse outcomes. Option C) Administer pain medication as prescribed may help alleviate the discomfort but does not address the underlying issue of a potential DVT. Option D) Encouraging the client to elevate the affected leg is generally beneficial for conditions like venous insufficiency but is not the most critical intervention when DVT is suspected. In an educational context, understanding the priority interventions for different conditions is vital for nurses to provide safe and effective care to patients. Recognizing the signs and symptoms of DVT and knowing the appropriate actions to take can prevent serious complications and improve patient outcomes.
Question 5 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.