ATI LPN
Questions About the Immune System Questions
Question 1 of 5
A nurse is caring for a child who is postoperative following surgical removal of a Wilms’ tumor. Which of the following assessments is an indication to continue NPO status?
Correct Answer: C
Rationale: The correct answer is C: Absent bowel sounds. Following surgical removal of a Wilms' tumor, absent bowel sounds indicate potential postoperative ileus, which can lead to complications if oral intake is resumed prematurely. Absence of bowel sounds may suggest a lack of peristalsis and require continued NPO status to prevent complications. A: Abdominal girth 1 cm larger than yesterday may indicate fluid retention or bloating, but it does not specifically warrant continued NPO status. B: Report of pain at the operative site is expected postoperatively and does not necessarily require NPO status. D: Passing of flatus every 30 min indicates bowel function and is a positive sign for resuming oral intake.
Question 2 of 5
A child is being treated for strep throat. The nurse tells the parent to report any abrupt onset of midabdominal pain along with malaise, irritability and fever. The nurse is teaching the parent signs of:
Correct Answer: B
Rationale: The correct answer is B: Acute post-streptococcal glomerulonephritis. This condition is a possible complication of strep throat caused by an immune response to the streptococcal infection affecting the glomeruli of the kidneys. The signs mentioned by the nurse (abrupt onset of midabdominal pain, malaise, irritability, and fever) are indicative of this condition. Sodium retention (choice A) is not associated with these specific signs. Hemolytic-uremic syndrome (choice C) typically presents with bloody diarrhea and kidney injury, not midabdominal pain. Renal insufficiency (choice D) may present with various symptoms but does not typically include midabdominal pain as a prominent sign.
Question 3 of 5
A child has been diagnosed with stage 3 chronic kidney disease (CKD). The nurse would question the medical order for:
Correct Answer: D
Rationale: The correct answer is D, Intravenous pyelogram with contrast to visualize kidneys. In stage 3 CKD, the kidneys are moderately damaged, making them vulnerable to further harm from contrast dye. The use of contrast dye can worsen kidney function and potentially lead to acute kidney injury. The other options (ACE inhibitor, erythropoietin therapy, iron replacement therapy, long-acting insulin) are appropriate treatments for complications of CKD and aim to manage blood pressure, anemia, and blood sugar levels, respectively. However, the use of contrast dye in this scenario poses a risk to the already compromised kidneys and should be avoided.
Question 4 of 5
An infant is born with an esophageal atresia and tracheoesophageal fistula. Which preoperative nursing diagnosis is the priority for this infant?
Correct Answer: A
Rationale: The correct answer is A: Risk for Aspiration Related to Regurgitation. This is the priority because the infant with esophageal atresia and tracheoesophageal fistula is at high risk for aspiration due to the abnormal connection between the esophagus and trachea. Aspiration can lead to serious complications such as pneumonia and respiratory distress. Addressing this risk is crucial for the infant's safety and well-being. Choice B (Acute Pain) is not the priority as aspiration poses a more immediate threat to the infant's health. Choice C (Ineffective Infant Feeding Pattern) is important but addressing the risk of aspiration takes precedence. Choice D (Ineffective Tissue Perfusion) is not directly related to the immediate danger of aspiration in this case. Prioritizing the prevention of aspiration is essential for the infant's safety and effective care.
Question 5 of 5
A school-age client, recently diagnosed with asthma, also has a peanut allergy. The nurse instructs the family to not only avoid peanuts but also to carefully check food label ingredients for peanut products and to make sure dishes and utensils are adequately washed prior to food preparation. The mother asks why this is specific for her child. Based on the client’s history, the nurse knows that this client is at an increased risk for which complication?
Correct Answer: C
Rationale: The correct answer is C: Anaphylaxis. Anaphylaxis is a severe and potentially life-threatening allergic reaction that can occur rapidly in individuals with peanut allergies. The client's history of asthma and peanut allergy puts them at a higher risk for experiencing anaphylaxis when exposed to peanuts. Anaphylaxis can cause symptoms such as difficulty breathing, swelling, a drop in blood pressure, and can be fatal if not treated promptly with epinephrine. A: Urticaria is a skin rash that can occur in response to an allergic reaction, but it is not as severe or life-threatening as anaphylaxis. B: Diarrhea is not typically a common symptom of an allergic reaction to peanuts and does not pose the same level of risk as anaphylaxis. D: Headache is not a common symptom of an allergic reaction to peanuts and is not as severe as anaphylaxis.