ATI RN
Pediatric Cardiovascular Disorders Nursing Questions
Question 1 of 5
During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?
Correct Answer: C
Rationale: In this scenario, option C is the most useful information in determining the possible cause of the exacerbation of eczema symptoms. The presence of a new dog can trigger allergic reactions in individuals with eczema due to pet dander and potential allergens present in the dog's fur or saliva. This information is crucial as it points towards a potential trigger for the worsening of symptoms. Option A is incorrect as the presence of a friend with eczema does not directly correlate with the exacerbation of the client's symptoms unless there was direct contact leading to an allergic reaction. Option B is less likely to be the cause as receiving an influenza immunization typically does not exacerbate eczema symptoms unless the client has a specific allergic reaction to the vaccine components. Option D is also less likely to be the cause as corticosteroid cream is a common treatment for eczema and should not worsen symptoms unless the cream itself is expired or contaminated. From an educational perspective, this question highlights the importance of understanding potential triggers for eczema exacerbations, such as exposure to new allergens like pet dander. It emphasizes the need for nurses to conduct thorough assessments and gather relevant information to identify and address the root cause of a client's worsening symptoms effectively.
Question 2 of 5
A client who took a camping vacation two weeks ago in a county with a tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for the nurse report to the healthcare provider?
Correct Answer: D
Rationale: The most important finding for the nurse to report to the healthcare provider in this scenario is option D) Jaundiced sclera. Jaundice is a serious sign of liver dysfunction, which could be indicative of a potential infection such as hepatitis, especially considering the recent travel to a tropical climate where infectious diseases may be more prevalent. Liver involvement can lead to serious complications, especially in pediatric patients. Option A) Weakness and fatigue are non-specific symptoms that can be associated with various conditions and may not provide a clear indication of the underlying issue. Option B) Intestinal cramping, while uncomfortable for the client, is a common symptom of diarrhea and may not necessarily point to a more serious condition. Option C) Weight loss, while significant, may be a consequence of the diarrhea and not necessarily the most critical finding requiring immediate attention. In an educational context, understanding the significance of specific symptoms and their implications in pediatric patients is crucial for nurses caring for children with potential health concerns. Recognizing the priority signs and symptoms to report to healthcare providers can lead to timely interventions and improved outcomes for pediatric patients.
Question 3 of 5
The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. What action should the nurse take?
Correct Answer: A
Rationale: In this scenario, the correct action for the nurse to take is Option A) Collect the blood sample. The reddened and engorged appearance of the distal tip of the finger after milking can be indicative of capillary refill, a sign that the circulation to the area is good. This means that the blood flow is adequate to obtain a reliable capillary blood sample for glucose testing. Option B) Assess radial pulse volume is incorrect because the appearance of the finger after milking does not necessarily correlate with the radial pulse volume. The focus here is on obtaining a blood sample for glucose testing, not on assessing pulse volume. Option C) Apply pressure to the site is incorrect as applying pressure can alter the blood flow to the area and potentially affect the accuracy of the glucose reading. Option D) Select another finger is also incorrect as the appearance of the finger is not a contraindication for collecting the blood sample. Educationally, this question highlights the importance of understanding the significance of capillary refill in relation to obtaining blood samples for testing. It reinforces the need for nurses to recognize normal physiological responses in pediatric clients and how these responses can impact nursing interventions. This knowledge is crucial in ensuring accurate assessments and appropriate care for pediatric patients.
Question 4 of 5
A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client's postoperative discharge instructions?
Correct Answer: D
Rationale: In the context of a client with urolithiasis post-lithotripsy, the correct intervention to include in postoperative discharge instructions is option D) Give IV dose of adenosine rapidly over 1-2 seconds. Adenosine is commonly used to treat supraventricular tachycardia, a condition that can occur as a complication of lithotripsy due to the stress and pain associated with the procedure. Rapid administration of adenosine can help restore normal sinus rhythm by temporarily blocking conduction through the atrioventricular node. Option A) Prepare for transcutaneous pacing is incorrect as it is not indicated in this situation. Transcutaneous pacing is used for bradycardia or heart blocks, not for supraventricular tachycardia. Option B) Deliver another defibrillator shock is also incorrect. Defibrillation is used for life-threatening arrhythmias like ventricular fibrillation or ventricular tachycardia, not for supraventricular tachycardia. Option C) Administer IV Epinephrine per ACLS protocol is not the correct choice either. Epinephrine is typically used in cardiac arrest situations to improve myocardial and cerebral perfusion, not for treating supraventricular tachycardia post-lithotripsy. Educationally, understanding the appropriate pharmacological interventions post-lithotripsy is crucial for nurses caring for patients with urolithiasis. It is important to differentiate between different types of arrhythmias and their respective treatments to provide safe and effective care to patients recovering from procedures like lithotripsy.
Question 5 of 5
During preoperative teaching for a male client scheduled for repair of an inguinal hernia, the client tells the nurse that he has had several surgeries and understands the need to perform coughing and deep breathing exercises after surgery. How should the nurse respond?
Correct Answer: A
Rationale: The correct answer is A) Ask for a demonstration of these exercises. This response is appropriate because it allows the nurse to assess the client's understanding of the coughing and deep breathing exercises. By asking for a demonstration, the nurse can ensure that the client is performing the exercises correctly, which is crucial for preventing postoperative complications such as atelectasis and pneumonia. Option B) Explain that coughing should be avoided is incorrect as coughing and deep breathing exercises are actually encouraged after surgery to promote lung expansion, improve oxygenation, and prevent respiratory complications. Option C) Review the client’s previous surgical history is not the most appropriate response in this situation as the client has already mentioned understanding the need for coughing and deep breathing exercises. Focusing on the current teaching and assessment of understanding is more relevant. Option D) Document the client's understanding of teaching is important but not sufficient on its own. While documentation is crucial, it does not actively assess the client's ability to perform the exercises correctly. In an educational context, this scenario highlights the importance of active assessment and validation of patient understanding in the teaching process. By asking for a demonstration, nurses can ensure that patients have the necessary skills and knowledge to care for themselves effectively postoperatively.