ATI RN
Burns Pediatric Primary Care Test Bank Questions
Question 1 of 5
Clients will go through operations and who have undergone surgery need the proper observation, treatment, and care. Implementing the nursing process to these patients will help reduce complications. Nurse Maria is preparing Mr. Sy for surgery. Which of the following statements by the client would indicate he is well-informed about his imminent surgery?
Correct Answer: B
Rationale: Option B, "I will not eat anything after 12 pm the night before my operation, but I sure can drink," indicates that the client understands and is knowledgeable about the pre-operative fasting guidelines. It is crucial for patients to have an empty stomach before surgery to prevent complications related to anesthesia, such as aspiration pneumonia. This statement shows that Mr. Sy is well-informed and compliant with this important pre-operative instruction. Options A, C, and D do not directly demonstrate specific knowledge regarding the surgery preparations.
Question 2 of 5
Aling Nena, 68 years old, had a MVA and underwent surgery for hip fracture. Two days post-surgery, she suddenly complained of chest heaviness despite the absence of cardiac history. What is the nursing priority?
Correct Answer: C
Rationale: In a post-operative patient, sudden chest heaviness can be a sign of various complications, such as a pulmonary embolism or cardiac issue. One of the immediate nursing interventions for a patient complaining of chest heaviness is to ensure adequate oxygenation. Administering oxygen via a face mask can help improve oxygenation and provide relief while further assessments are being done to determine the cause of the symptom. This intervention takes priority over documenting the symptom, offering analgesics, or informing the physician, as addressing the patient's oxygen needs is crucial in this situation.
Question 3 of 5
A guest who is diabetic attended a bridal affair. The guest started to tremble and started to feel dizzy. Luckily a nurse is present. The best action for the nurse to take is to:
Correct Answer: D
Rationale: The best action for the nurse to take in this situation is to give the guest a glass of orange juice (Choice D). The guest is most likely experiencing hypoglycemia (low blood sugar) due to diabetes. Orange juice contains natural sugars that can help raise the guest's blood sugar levels quickly. Since the guest is feeling dizzy and trembling, providing a source of fast-acting sugar like orange juice is crucial in addressing the low blood sugar and preventing the situation from worsening. It is important to follow up with a source of longer-lasting carbohydrates and protein after the guest's blood sugar levels have stabilized.
Question 4 of 5
. Which of the following laboratory test results would the nurse expect to find in a client diagnosed with Hashimoto's thyroiditis?
Correct Answer: E
Rationale: Hashimoto's thyroiditis is an autoimmune disorder that results in an underactive thyroid gland (hypothyroidism). The key lab findings typically seen in Hashimoto's thyroiditis include elevated thyroid antibodies (such as anti-thyroid peroxidase and anti-thyroglobulin antibodies), decreased levels of thyroxine (T4) and triiodothyronine (T3), and an elevated thyroid-stimulating hormone (TSH) level.
Question 5 of 5
Which nursing diagnosis is most appropriate for a client with Addison's disease?
Correct Answer: C
Rationale: Addison's disease is a condition characterized by adrenal insufficiency, resulting in a deficiency of aldosterone and cortisol. Without aldosterone, the body is unable to regulate fluid and electrolyte balance properly, leading to sodium loss and potassium retention. This imbalance can result in excessive fluid volume, as the kidneys retain water and sodium. Symptoms of excessive fluid volume in Addison's disease can include edema, weight gain, and hypertension. Therefore, the most appropriate nursing diagnosis for a client with Addison's disease would be Excessive Fluid Volume.