ATI LPN
Immune System Questions Questions
Question 1 of 5
A school-age child with hemophilia falls on the playground and goes to the school nurse with superficial bleeding above the elbow. What is the most appropriate action by the nurse?
Correct Answer: B
Rationale: The correct answer is B: Apply pressure for at least 15 minutes. This is the most appropriate action as it helps control bleeding by promoting clot formation. Applying pressure directly on the wound site can help stop the bleeding effectively. Warm, moist compresses (choice A) may not provide enough direct pressure to stop bleeding. Keeping the affected extremity in a dependent position (choice C) can increase bleeding due to gravity. Beginning passive range of motion (choice D) could exacerbate bleeding if a clot has not formed yet. Therefore, applying pressure for at least 15 minutes is the best initial action to control bleeding in this situation.
Question 2 of 5
The nurse is administering packed red blood cells to a child with sickle cell disease (SCD). The nurse is monitoring for a transfusion reaction and knows it is most likely to occur during which time frame?
Correct Answer: B
Rationale: The correct answer is B: Within the first 20 minutes of administration of the transfusion. During the initial stage of transfusion, reactions are most likely to occur due to rapid infusion of blood. This is when the nurse should closely monitor the child for signs of transfusion reactions such as fever, chills, rash, or shortness of breath. Reactions can be severe and life-threatening, so early detection is crucial. Choices A, C, and D are incorrect because reactions are most likely to occur at the beginning of the transfusion due to immediate immune responses, rather than hours later, at the end of the transfusion, or not at all.
Question 3 of 5
A client with disseminated intravascular coagulation (DIC) is experiencing joint pain. Which nursing intervention is appropriate for this client?
Correct Answer: A
Rationale: The correct answer is A: Splints. Splints help immobilize joints, reducing pain and preventing further damage in clients with joint pain due to DIC. Cool compresses (B) may provide temporary relief but won't address the underlying issue. Heat (C) can worsen inflammation in joints. Ice (D) is contraindicated in DIC as it can exacerbate clotting issues.
Question 4 of 5
A child is diagnosed with thrombocytopenia secondary to chemotherapy treatments. Which action by the nurse is not appropriate?
Correct Answer: A
Rationale: The correct answer is A: Administer intramuscular injections (IM). In a child with thrombocytopenia, the platelet count is low, leading to an increased risk of bleeding. Administering IM injections can cause bleeding at the injection site due to the potential trauma to blood vessels. Performing oral hygiene (B), monitoring intake and output (C), and using palpation as a component of assessment (D) are appropriate actions that do not pose a significant risk of bleeding in a child with thrombocytopenia. It is crucial to prioritize interventions that minimize the risk of bleeding complications in this scenario.
Question 5 of 5
Which of the following would be an appropriate nursing diagnosis for a child who is receiving chemotherapy?
Correct Answer: D
Rationale: The correct answer is D: Impaired oral mucous membrane. This is an appropriate nursing diagnosis for a child receiving chemotherapy because chemotherapy often causes mucositis, leading to pain, difficulty eating, and an increased risk of infection in the oral cavity. Nurses need to assess and monitor oral mucous membranes closely in these patients. Incorrect choices: A: Ineffective breathing pattern - Not directly related to chemotherapy in this scenario. B: Constipation - Not typically a common issue specifically related to chemotherapy. C: Impaired skin integrity - Not directly related to the side effects of chemotherapy on oral mucous membranes.