ATI RN
Wongs Essentials of Pediatric Nursing 11th Edition Test Bank Questions
Question 1 of 5
A nurse has been examining the vital signs of the client for the past 2 days. On a particular day, she observe a sudden change in the vital signs of the client. Which of the ff steps should the nurse take immediately?
Correct Answer: A
Rationale: The nurse should immediately inform the physician about the sudden change in the client's vital signs. Sudden changes in vital signs can be indicative of a serious health issue or medical emergency that would require the expertise and intervention of a physician. Prompt communication with the physician is essential to ensure timely assessment, diagnosis, and appropriate treatment for the client. It is crucial to prioritize the client's well-being and safety in such situations, which is why informing the physician is the most appropriate and urgent step to take.
Question 2 of 5
The client is taking phenyton (Dilantin) for seizure control. A sample is drawn to determine the serum drug level, and the nurse reviews the results. Which of the following would indicate a therapeutic serum drug range?
Correct Answer: A
Rationale: The therapeutic serum drug range for phenytoin (Dilantin) is typically considered to be 10 to 20 mcg/ml. However, some sources may cite a broader range of 5 to 20 mcg/ml. Therefore, a serum drug level range of 5 to 10 mcg/ml would fall within the acceptable therapeutic range for phenytoin. Serum levels outside of this range may indicate potential toxicity (above range) or subtherapeutic levels (below range) which could result in inadequate seizure control.
Question 3 of 5
Which of the following would the nurse use to document a finding that the patient's ear is draining?
Correct Answer: A
Rationale: Otorrhea is the medical term used to describe drainage from the ear. It is a finding that indicates the ear is draining fluid, which can be a sign of infection or other underlying issues. Otalgia refers to ear pain, ototoxic refers to substances that can damage the ear, and tinnitus refers to ringing in the ears. Therefore, otorrhea is the most appropriate term to document the finding of a draining ear.
Question 4 of 5
Which of the ff. safety instructions should the nurse give a patient who has temporarily dilated pupils?
Correct Answer: B
Rationale: Dilated pupils can cause increased sensitivity to light, leading to discomfort or visual disturbances. Wearing sunglasses can help protect the eyes from bright light and reduce potential discomfort for the patient. This safety instruction is important to promote the patient's comfort and prevent any potential harm due to light sensitivity.
Question 5 of 5
Early this morning a client had a subtotal thyroidectomy. During evening rounds, the nurse assesses the client, who has now nausea, a temperature of 105F (40.5C), tachycardia, and extreme restlessness. What is the most likely cause of these signs?
Correct Answer: C
Rationale: The signs and symptoms described - nausea, elevated temperature, tachycardia, and extreme restlessness - are indicative of a thyroid crisis, also known as thyroid storm. A thyroid storm is a life-threatening condition that can occur after thyroid surgery such as a subtotal thyroidectomy. It is characterized by an exaggerated state of hyperthyroidism, leading to a surge of thyroid hormones in the bloodstream. This can result in severe symptoms such as high fever, tachycardia, nausea, agitation, and even confusion or delirium.