ATI RN
Pediatrics Baby Fell off Bed Questions Questions
Question 1 of 5
An adult has been diagnosed with some type of anemia. The results of his blood tests showed: decreased WBC, normal RBC, decreased HCT, decreased Hgb. Based on these data, which of the following nursing diagnosis should the nurse prioritize as the most important?
Correct Answer: A
Rationale: The decreased white blood cell count (WBC) in the blood tests indicates a potential for infection. White blood cells are crucial for fighting off infections in the body. A decrease in WBC count can result in an impaired immune response, making the individual more susceptible to infections. Therefore, the nurse should prioritize the nursing diagnosis of "Potential for infection" to address the heightened risk of infection in the adult with anemia. It is important to monitor for signs and symptoms of infection, provide appropriate hygiene measures, and implement interventions to prevent infections in this individual.
Question 2 of 5
A client has been receiving chemotherapy to treat cancer. Which assessment finding suggests that the client has developed stomatitis (inflammation of the mouth)?
Correct Answer: B
Rationale: Stomatitis is a common side effect of chemotherapy characterized by inflammation and irritation of the mucous membranes in the mouth. This can present as red, painful sores or ulcers on the oral mucosa. The presence of red, open sores in the mouth is indicative of stomatitis and warrants assessment and intervention to manage discomfort and prevent infection in the oral cavity. The other options are not typically associated with stomatitis in the context of chemotherapy.
Question 3 of 5
A client is hospitalized with oat cell carcinoma of the lung. To manage severe pain, the physician prescribes a continuous I.V. infusion of morphine. Which formula should the nurse use to check that the morphine dose is appropriate for the client?
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 4 of 5
A client is receiving methotrexate (Mexate), 12g/m2 IV to treat osteogenic carcinoma. During methotrexate therapy, the nurse expects the client to receive which other drug to protect normal cells?
Correct Answer: D
Rationale: Leucovorin, also known as folinic acid, is given concurrently with methotrexate therapy to protect normal cells from the toxic effects of methotrexate. Methotrexate is a folate antagonist that affects both cancer cells and normal cells. Leucovorin is a reduced form of folic acid that bypasses the enzyme targeted by methotrexate, allowing normal cells to continue using folate for DNA synthesis. This rescue therapy helps prevent or reduce the side effects of methotrexate, such as mucositis, myelosuppression, and other toxic effects on normal cells. It is important to administer leucovorin at the appropriate times following methotrexate administration to maximize its protective effect while maintaining the efficacy of the chemotherapy.
Question 5 of 5
A client in the final stages of terminal cancer tells the nurse: "I wish I could be just be allowed to die. I'm tired of fighting this illness. I have lived life a good life. I only continue my chemotherapy and radiation treatment because my family wants me to." What is the best nurse's best response?
Correct Answer: A
Rationale: The best response for the nurse to provide in this situation is to offer the client the option to talk to a psychologist about their thoughts and feelings. This demonstrates the nurse's understanding and compassion towards the client's emotional struggles and the complexity of their situation. By suggesting a professional to talk to, the nurse can provide the client with the appropriate support and guidance to help them navigate their feelings of wanting to be allowed to die. It also allows the client to voice their concerns and emotions with a trained professional who can offer them coping strategies and support tailored to their individual needs.