ATI RN
Burns Pediatric Primary Care 7th Edition Test Bank Questions
Question 1 of 5
A patient returns from surgery ff. a TURP with a three-way Foley catheter and continuous bladder irrigation. Postoperative orders include Meperidine (Demerol) 75 mg IM q3h as needed for pain, belladonna and opium (B&O) suppository q4h as needed, and strict I&O. the patient complains of painful bladder spasms, and the nurse observes blood-tinged urine on the sheets. Which action should the nurse take?
Correct Answer: D
Rationale: The nurse should notify the physician stat in this situation. The presence of blood-tinged urine and painful bladder spasms in a patient with a three-way Foley catheter and continuous bladder irrigation post TURP could indicate a potential complication such as hemorrhage or clot retention. It is crucial to ensure prompt medical evaluation and intervention to address these issues effectively. Waiting or administering pain medication without further assessment could delay necessary treatment and lead to worsening of the patient's condition. Therefore, notifying the physician immediately is the most appropriate action in this scenario.
Question 2 of 5
A community nurse will perform chest physiotherapy for Mrs. Dy every 3 hours. It is important for the nurse to:
Correct Answer: C
Rationale: Performing chest physiotherapy (CPT) at least two hours after meals is important to prevent potential risks such as vomiting and aspiration. This timing allows for better tolerance of the procedure and decreases the likelihood of complications. By waiting at least two hours after meals, the nurse ensures that the patient's stomach is not full, reducing the risk of regurgitation during the chest physiotherapy session. This practice promotes the safety and well-being of the patient while undergoing this treatment.
Question 3 of 5
What is the most important postoperative instruction the nurse must give a client who has just returned from the operating room after receiving a subarachnoid block?
Correct Answer: D
Rationale: After receiving a subarachnoid block, the client may experience a sudden drop in blood pressure that can lead to complications such as dizziness or fainting upon standing. Therefore, it is crucial for the client to remain in a supine position for the duration specified by the physician to allow for proper monitoring and management of any potential postoperative complications. This instruction helps prevent the occurrence of hypotension and other adverse effects by allowing adequate time for the block to wear off and for the body to adjust to changes in blood pressure. It also ensures the safety and well-being of the client during the immediate postoperative period.
Question 4 of 5
When educating parents regarding known antecedent infections in acute glomerulonephritis, which of the following should the nurse cover?
Correct Answer: B
Rationale: When educating parents regarding known antecedent infections in acute glomerulonephritis, the nurse should cover impetigo. Acute poststreptococcal glomerulonephritis (APSGN) is commonly triggered by a streptococcal infection, such as impetigo or strep throat. Impetigo, a superficial skin infection caused by Staphylococcus aureus or Streptococcus pyogenes, is a common precursor to APSGN in children. Therefore, educating parents about impetigo and its potential link to acute glomerulonephritis is crucial in helping them recognize and manage their child's health effectively.
Question 5 of 5
During the physical assessment, the nurse recalls that the areas most frequently affected by multiple sclerosis are the:
Correct Answer: C
Rationale: Multiple sclerosis (MS) is a disease that primarily affects the central nervous system (CNS) by causing inflammation, damage, and scarring in the myelin sheath that covers nerve fibers. The optic nerve and chiasm are common areas affected by MS, leading to symptoms such as blurred or double vision, loss of color vision, and pain with eye movement. This involvement is known as optic neuritis, a common early symptom of MS. While MS can affect various parts of the CNS, the optic nerve and chiasm are among the most frequently involved areas, making choice C the correct answer in this case.