ATI RN
Pediatric Nursing Cardiovascular NCLEX Practice Quiz Questions
Question 1 of 5
A male client who had abdominal surgery 5 days ago, and hospitalized because of a surgical wound infection, tells the nurse that he feels like his insides just spilled out when he coughed. What action should the nurse take first?
Correct Answer: C
Rationale: In this scenario, the correct action for the nurse to take first is to visualize the abdominal incision (Option C). This is important because the client's complaint of feeling like his insides spilled out when coughing could indicate dehiscence or evisceration of the surgical wound, which are serious complications requiring immediate attention. By visualizing the incision, the nurse can assess for any signs of wound disruption, such as separation of wound edges or protrusion of abdominal contents. Option A, notifying the healthcare provider, is not the first action to take in this situation because the nurse needs to assess the client's condition firsthand before escalating the issue. Option B, assuring the client that such feelings occur with wound infections, is incorrect as it overlooks the potential seriousness of the situation and delays necessary intervention. Option D, obtaining sterile towels soaked in saline, is also not the priority as it does not address the immediate need to assess the wound. Educationally, this question highlights the importance of prompt assessment and intervention in postoperative care, especially when complications such as wound dehiscence or evisceration are suspected. Nurses must be vigilant in monitoring surgical wounds for any signs of complications to prevent further harm to the client. This scenario underscores the critical role of nursing assessment in identifying and managing postoperative complications effectively.
Question 2 of 5
When explaining dietary guidelines to a client with acute glomerulonephritis (AGN), which instruction should the nurse include in the dietary teaching?
Correct Answer: A
Rationale: In the context of a client with acute glomerulonephritis (AGN), the nurse should include the instruction to restrict sodium intake in the dietary guidelines. Sodium restriction is crucial in managing AGN because excessive sodium can lead to fluid retention and hypertension, which can further damage the already compromised kidneys in AGN. By limiting sodium intake, the client can help reduce fluid retention and manage blood pressure, thus supporting kidney function. Encouraging high-protein foods (option B) is not appropriate in AGN because excessive protein intake can increase the workload on the kidneys, potentially worsening the condition. Similarly, increasing potassium intake (option C) is not advisable as impaired kidney function in AGN can lead to hyperkalemia, making it important to monitor and potentially restrict potassium intake. Decreasing fluid intake (option D) may be necessary in some cases of AGN to manage fluid overload, but it is not the primary dietary guideline for this condition. In AGN, sodium restriction takes precedence over fluid restriction as excess sodium can contribute to fluid retention and hypertension, both of which can worsen kidney function. In an educational context, understanding the rationale behind dietary guidelines in specific conditions like AGN is crucial for nurses to provide effective patient care. By explaining the reasons behind dietary recommendations, nurses can empower clients to actively participate in their care and make informed choices to support their health outcomes.
Question 3 of 5
The nurse is providing discharge instructions to a client who is receiving prednisone (Deltasone) 5 mg PO daily for a rash due to contact with poison ivy. Which symptom should the nurse tell the client to report to the healthcare provider?
Correct Answer: A
Rationale: In this scenario, the correct answer is A) Rapid weight gain. Prednisone, a corticosteroid, can cause fluid retention and sodium retention in the body, leading to weight gain. Rapid weight gain may indicate fluid overload, a serious side effect that needs immediate medical attention to prevent complications such as heart failure or edema. Option B) Increased energy levels is incorrect because prednisone typically causes side effects such as insomnia, mood changes, or nervousness, but not necessarily increased energy levels. Option C) Frequent headaches are not a common side effect of prednisone and would not be a priority symptom to report. Option D) Dry mouth is a common side effect of prednisone, but it is usually not a serious symptom that requires immediate medical attention. Educationally, this question emphasizes the importance of understanding the side effects of medications commonly prescribed in pediatric patients, the significance of monitoring for adverse reactions, and the need for clear patient education to ensure timely reporting of concerning symptoms to healthcare providers. Nurses need to be vigilant in educating patients and caregivers about potential side effects of medications, especially in pediatric populations where monitoring for adverse reactions is crucial.
Question 4 of 5
The nurse is monitoring an infant with a congenital heart disease closely for signs of heart failure. Which early sign should the nurse be most concerned about?
Correct Answer: C
Rationale: In pediatric nursing, understanding the early signs of heart failure in infants with congenital heart disease is crucial for timely intervention. In this scenario, the correct answer is C) Tachycardia. Tachycardia, an elevated heart rate, is a significant early sign of heart failure in infants. It indicates the heart's inability to meet the body's oxygen demands, leading to compensatory mechanisms like increased heart rate. Option A) Pallor is a non-specific sign that can occur in various conditions and may not specifically indicate heart failure in this context. Option B) Cough is more commonly associated with respiratory issues rather than early signs of heart failure. Option D) Slow and shallow breathing can be a late sign of heart failure, whereas tachycardia is an earlier indicator. Educationally, understanding these nuanced differences is crucial for nurses caring for pediatric patients with cardiac conditions. Recognizing early signs of deterioration can prompt swift interventions, potentially preventing adverse outcomes. Nurses must be vigilant in monitoring these subtle changes in infants to provide timely and effective care.
Question 5 of 5
The clinic nurse reviews the record of a child just seen by the health care provider and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder?
Correct Answer: C
Rationale: In the case of a child diagnosed with suspected aortic stenosis, the nurse would expect to note documentation of exercise intolerance as a specific clinical manifestation. Aortic stenosis is a condition characterized by narrowing of the aortic valve, leading to decreased cardiac output and poor perfusion to the body. This results in the child experiencing difficulty in engaging in physical activities and showing signs of exercise intolerance due to the heart's inability to meet the body's increased demand for oxygen during exertion. Option A, pallor, is a non-specific finding that can occur in various health conditions and is not specifically associated with aortic stenosis. Option B, hyperactivity, is unrelated to the pathophysiology of aortic stenosis and would not be a typical manifestation of this disorder. Option D, gastrointestinal disturbances, are also not commonly associated with aortic stenosis. Educationally, understanding the clinical manifestations of pediatric cardiovascular disorders is crucial for nurses caring for children with such conditions. Recognizing specific signs and symptoms can aid in early identification, prompt intervention, and improved outcomes for pediatric patients with cardiovascular issues. By mastering these concepts, nurses can provide comprehensive care and support to pediatric patients with aortic stenosis and other cardiovascular conditions.