ATI RN
Pediatric Cardiovascular Disorders Nursing Questions
Question 1 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 2 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 3 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.
Question 4 of 5
In assessing a client with ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin?
Correct Answer: B
Rationale: In assessing a client with ulcers on the lower extremity, findings that indicate venous ulcers over arterial ulcers are irregular ulcer shapes and severe edema. Venous ulcers tend to have irregular shapes due to the underlying venous hypertension, while arterial ulcers are typically more uniform in shape. Severe edema is also more characteristic of venous insufficiency, as impaired venous return leads to fluid accumulation in the tissues. Option A, black ulcers and dependent rubor, are more indicative of arterial ulcers. Black ulcers suggest ischemia and necrosis, while dependent rubor is a sign of arterial insufficiency. Option C, absent pedal pulses and shiny skin, are also more indicative of arterial ulcers, as impaired arterial blood flow leads to diminished pulses and shiny, atrophic skin. Option D, hairless lower extremities and cool feet, can be seen in both arterial and venous insufficiency, but are not as specific to venous ulcers as irregular ulcer shapes and severe edema. Educationally, understanding the differences in presentation between venous and arterial ulcers is crucial for nurses caring for patients with cardiovascular disorders. Recognizing these differences can guide appropriate interventions and help prevent complications associated with mismanagement of these conditions.
Question 5 of 5
An older male client with long-standing lung disease is admitted to the medical unit for treatment of pulmonary infection. In assessing for signs of increasing hypoxia, which action should the nurse include? (select all that apply)
Correct Answer: B
Rationale: In this scenario, the correct action the nurse should include in assessing for signs of increasing hypoxia in an older male client with long-standing lung disease is to check for changes in mentation (Option B). This is because changes in mentation, such as confusion or altered level of consciousness, can be early indicators of worsening hypoxia in patients with lung disease. Monitoring dryness of mucous membranes (Option A) is not a reliable indicator of hypoxia in this case because it is more specific to hydration status rather than oxygenation. Observing the color of skin and nailbeds (Option C) is important for assessing oxygenation, but it is a later sign of hypoxia. Noting the appearance of jugular veins (Option D) is not directly related to assessing hypoxia in this context. Educationally, it is important for nurses to understand the various signs and symptoms of hypoxia in patients with respiratory conditions, as early recognition and intervention are crucial in preventing adverse outcomes. Checking for changes in mentation can provide valuable information about the client's oxygenation status and help guide appropriate nursing interventions.