ATI LPN
Immune System Questions Questions
Question 1 of 5
Another name for platelets is:
Correct Answer: A
Rationale: Platelets are also known as thrombocytes. This is the correct answer because thrombocytes are responsible for blood clotting. Platelets play a crucial role in preventing excessive bleeding. Lymphocytes, erythrocytes, and leucocytes are different types of blood cells with distinct functions unrelated to blood clotting.
Question 2 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 3 of 5
When completing the child’s admission assessment, which of the following components of the abdominal assessment should the nurse avoid?
Correct Answer: B
Rationale: The correct answer is B: Palpation. During a child's admission assessment, the nurse should avoid palpation of the abdomen because it can potentially cause discomfort or pain to the child, especially if there is an underlying abdominal issue. Instead, the nurse should prioritize other components such as inspection, auscultation, and percussion. Inspection allows the nurse to visually assess the abdomen for any abnormalities or distension. Auscultation helps in listening for bowel sounds, which can provide valuable information about gastrointestinal function. Percussion can assist in identifying areas of tenderness or abnormal fluid accumulation. Palpation should be performed cautiously and only if necessary, after obtaining consent and ensuring the child is comfortable.
Question 4 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 5 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.