ATI RN
Pediatric Nursing Cardiovascular NCLEX Practice Quiz Questions
Question 1 of 5
After a transurethral resection of the prostate (TURP), a client has bloody urine output with large clots. The nurse implements the postoperative prescription to irrigate the indwelling catheter PRN to maintain the catheter's patency. Which action should the nurse implement?
Correct Answer: A
Rationale: In this scenario, the correct action is to clamp the catheter for 30 minutes prior to irrigating with saline (Option A). This process allows the clots to soften and break up, making it easier to clear the catheter without causing trauma. Option B (Manually irrigate the catheter with sterile saline) is incorrect because directly irrigating without clamping can potentially push the clots further into the catheter, leading to blockage. Option C (Increase the client's oral fluid intake) is not the immediate solution to clearing the catheter of clots. While hydration is essential, it may not be effective in dislodging existing clots. Option D (Remove the catheter and notify the healthcare provider immediately) is inappropriate as removing the catheter without attempting to clear the clots first could lead to urinary retention and potential complications for the client. Educationally, understanding the rationale behind clamping the catheter before irrigation post-TURP is crucial in preventing complications and ensuring proper postoperative care. This knowledge is essential for pediatric nurses to provide safe and effective care to their patients undergoing urological procedures.
Question 2 of 5
The nurse is evaluating a male client’s understanding of diet teaching about the DASH (Dietary Approaches to Stop Hypertension) eating plan. Which behavior indicates that the client is adhering to the eating plan?
Correct Answer: D
Rationale: The correct answer is D) Carefully cleans and peels all fresh fruit and vegetables. This behavior indicates adherence to the DASH eating plan because it emphasizes consuming a diet rich in fruits and vegetables, which are important sources of essential nutrients and fiber. By cleaning and peeling fresh produce, the client is ensuring that he is consuming them in a safe and healthy manner. Option A is incorrect because using only lactose-free dairy products is not a specific requirement of the DASH eating plan. Option B is incorrect because while fat-free yogurt can be a part of a healthy diet, enjoying it as an occasional snack food does not necessarily demonstrate adherence to the DASH eating plan. Option C is incorrect because excluding grains entirely from the daily diet goes against the recommendations of the DASH eating plan, which actually encourages whole grains as part of a balanced diet. In an educational context, understanding the principles of the DASH eating plan is crucial for managing hypertension in pediatric patients. Teaching clients about the importance of consuming a diet rich in fruits, vegetables, whole grains, lean proteins, and low-fat dairy products can help them improve their cardiovascular health and overall well-being. Encouraging behaviors such as cleaning and peeling fresh produce can ensure that clients are following the DASH eating plan effectively.
Question 3 of 5
A hospitalized client with chemotherapy-induced stomatitis complains of mouth pain. What is the best initial nursing action?
Correct Answer: D
Rationale: In this scenario, the best initial nursing action for a hospitalized client with chemotherapy-induced stomatitis complaining of mouth pain is to administer a topical analgesic per PRN protocol (Option D). This is the correct choice because a topical analgesic can provide direct relief to the specific area of pain in the mouth, offering immediate comfort to the client. Encouraging frequent mouth care (Option A) is important for overall oral health but may not address the immediate pain concern. Cleansing the tongue and mouth with glycerin swabs (Option B) can be soothing but may not provide adequate pain relief. Obtaining a soft diet for the client (Option C) is beneficial for comfort but does not directly address the pain concern as effectively as administering a topical analgesic. Educationally, it is essential for nursing students to understand the importance of prompt pain management in clients experiencing discomfort, especially in vulnerable populations like pediatric patients undergoing chemotherapy. By selecting the correct option, students learn the significance of assessing and addressing acute pain to improve the overall quality of care provided to patients.
Question 4 of 5
An adult female with multiple sclerosis (MS) falls while walking to the bathroom. On transfer to the intensive care unit, she is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?
Correct Answer: D
Rationale: The correct answer to this question is D) Complete head to toe neurological assessment. In this scenario, the patient's symptoms of confusion and projectile vomiting after a fall raise concerns about potential head injury or increased intracranial pressure. A head to toe neurological assessment is crucial in this situation to quickly identify any neurological deficits, assess for signs of increased intracranial pressure, and determine the extent of the injury. Option A) Determine client's last dose of corticosteroids is not the most appropriate initial intervention because in this case, the priority is to assess the patient's neurological status and ensure their safety. Option B) Determine neurological baseline prior to the fall is not the priority at this moment as the patient's current condition post-fall needs immediate attention. Option C) Administer a PRN IV antiemetic as prescribed is not the first intervention to implement because the patient's symptoms of confusion and vomiting are suggestive of a more urgent neurological issue that needs to be addressed first. In an educational context, it is essential for nurses to prioritize interventions based on the patient's presenting symptoms and potential life-threatening conditions. Understanding the importance of rapid assessment and recognizing signs of neurological compromise is critical in providing safe and effective care to patients, especially in emergent situations like this one.
Question 5 of 5
The nurse reviews the laboratory results of a client during an annual physical examination and identifies a positive guaiac test of stool. Which additional serum laboratory test result should the nurse review?
Correct Answer: B
Rationale: In this scenario, the correct answer is B) Platelet count. A positive guaiac test of stool indicates the presence of occult (hidden) blood in the stool, which could be a sign of gastrointestinal bleeding. Platelet count is crucial in assessing for bleeding disorders or conditions that could lead to gastrointestinal bleeding. Platelets are essential for blood clotting, and a low platelet count could result in prolonged bleeding. Option A) Glucose is not directly related to the positive guaiac test result. Elevated glucose levels would be more indicative of diabetes. Option C) White blood cell count is not typically associated with a positive guaiac test result. White blood cells are more indicative of infection or inflammation. Option D) Amylase is an enzyme involved in the digestion of carbohydrates and is not directly related to occult blood in the stool. Educationally, understanding the rationale behind the need to review platelet count in this case reinforces the importance of interpreting laboratory results in a holistic manner. It also highlights the significance of recognizing the implications of abnormal findings, such as occult blood in the stool, and the need for further investigation to determine the underlying cause. This knowledge is crucial for nurses caring for pediatric patients to ensure timely and appropriate interventions for their well-being.