ATI LPN
Questions About the Immune System Questions
Question 1 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 2 of 5
The mother of a 14-month-old child is concerned because the child’s appetite has decreased. The best response for the nurse to make to the mother is:
Correct Answer: B
Rationale: The correct answer is B: It is not unusual for toddlers to eat less. Toddlers often go through phases where their appetites fluctuate, and it is normal for them to eat less at times. This response reassures the mother that her child's decreased appetite is a common phenomenon among toddlers and typically not a cause for concern. Rationale: - A (It is important for your toddler to eat three meals a day and nothing in between): This answer is too rigid and may cause unnecessary stress for the mother. Toddlers may have varying eating patterns, and forcing them to adhere to a strict meal schedule can be counterproductive. - C (Be sure to increase your child’s milk consumption, which will improve nutrition): Increasing milk consumption may not necessarily improve nutrition and could lead to other issues such as iron deficiency. It is important to focus on a balanced diet rather than solely relying on milk. - D (Giving your child a multivitamin supplement daily will increase your toddler’s
Question 3 of 5
A child diagnosed with tetralogy of Fallot becomes upset, crying and thrashing around when a blood specimen is obtained. The child’s color becomes blue and respiratory rate increases to 44 bpm. Which of the following actions would the nurse do first?
Correct Answer: D
Rationale: The correct answer is D: Place the child in knee-to-chest position. This position helps improve blood flow to the lungs by reducing the amount of blood shunted away from the lungs in tetralogy of Fallot. It can help alleviate cyanosis and respiratory distress. This action should be done first to address the immediate physiological need of the child. Choice A: Obtaining sedation may be necessary, but addressing the physiological distress should take precedence. Choice B: Assessing for an irregular heart rate and rhythm is important but not the immediate priority in this situation. Choice C: Explaining to the child may be helpful for preparation, but addressing the physiological distress is the priority.
Question 4 of 5
A 3-month-old infant has a hypercyanotic spell. The nurse’s first action should be which of the following?
Correct Answer: D
Rationale: The correct answer is D: Place child in the knee-chest position. This is the first action to relieve hypercyanotic spells in infants with Tetralogy of Fallot. Placing the child in the knee-chest position increases systemic vascular resistance, reduces venous return to the heart, and improves pulmonary blood flow. This helps alleviate the cyanosis by decreasing the right-to-left shunting of blood. Assessing for neurologic defects (A) is not the priority in this situation. Preparing the family for imminent death (B) is premature and not appropriate as the first action. Beginning cardiopulmonary resuscitation (C) is not indicated unless the infant becomes unresponsive.
Question 5 of 5
When caring for the child with Kawasaki disease, the nurse should know which of the following?
Correct Answer: D
Rationale: The correct answer is D because therapeutic management of Kawasaki disease includes administration of gamma globulin to reduce the risk of coronary artery abnormalities and salicylates for anti-inflammatory effects. A is incorrect because aspirin is actually indicated for Kawasaki disease. B is incorrect as the principal area of involvement is the coronary arteries, not the joints. C is incorrect because Kawasaki disease is not responsive to antibiotics as it is an autoimmune disease.