ATI RN
Pediatric CCRN Practice Questions Questions
Question 1 of 5
Following the American Cancer Society guidelines, the nurse should recommend that the women:
Correct Answer: C
Rationale: The American Cancer Society recommends that women have a mammogram annually, starting at age 45, and then have the option to switch to every two years starting at age 55. This is based on evidence showing that regular mammograms can help detect breast cancer early when it is most treatable. Breast self-examinations are no longer recommended as a routine screening method due to studies showing they do not reduce mortality from breast cancer. Clinical breast exams conducted by a physician are also not recommended for routine screening in average-risk women, as they have not been shown to be effective in reducing breast cancer mortality. Normal receptor assay testing is not a screening test for breast cancer and is used to help determine the best treatment options for diagnosed breast cancer cases.
Question 2 of 5
The patient is dangling at the bedside and states, "Oh, my stomach is tearing open." Which of the following actions should the nurse immediately take when dehiscence occurs?
Correct Answer: B
Rationale: When dehiscence, which is the separation of the layers of a surgical incision, occurs in a patient, it is important to have the patient lie down. This position will help decrease intra-abdominal pressure and reduce the risk of further complications. Having the patient sit upright in a chair can increase intra-abdominal pressure, worsening the dehiscence. Slowing IV fluids may be necessary to prevent fluid overload in certain situations, but it is not the immediate action required when dehiscence occurs. Obtain a sterile suture set may eventually be needed, but the priority in this situation is to stabilize the patient by having them lie down.
Question 3 of 5
To monitor the severity of a patient's heart failure, which of the ff. assessments is the most appropriate for the nurse to include as a daily assessment in the plan of care?
Correct Answer: A
Rationale: Monitoring a patient's weight is a crucial assessment in heart failure management. Sudden weight gain could indicate fluid retention, which is a common sign of worsening heart failure. By regularly monitoring the patient's weight, the nurse can detect early signs of fluid buildup and adjust the treatment plan accordingly. Weight monitoring is a simple yet effective way to assess the severity of heart failure and prevent complications. The other options (B. Appetite, C. Calorie count, D. Abdominal girth) are not as directly related to monitoring heart failure severity as weight measurement.
Question 4 of 5
Which points should a nurse includes in the discharge teaching plan for a client after cardiac surgery?
Correct Answer: B
Rationale: The correct answer is B. In the discharge teaching plan for a client after cardiac surgery, it is important for the nurse to include education on monitoring for signs of complications, such as notifying the physician if a painless lump is felt at the top of the chest incision. This could potentially indicate a seroma or hematoma, which may require medical attention. By educating the client on this specific point, the nurse helps to promote early detection and prompt management of any post-operative issues, which contributes to better outcomes for the client. The other options mentioned are important aspects of post-cardiac surgery care but do not address the specific concern of a painless lump at the chest incision site.
Question 5 of 5
Which of the ff is a nursing intervention to ensure that the client is free from injury caused by falls?
Correct Answer: B
Rationale: Monitoring for swelling and heaviness of legs is a nursing intervention that can help prevent falls. Swelling and heaviness of legs could indicate conditions such as edema or circulation problems, which may increase the risk of falls due to impaired mobility and stability. By identifying these signs early on, the nurse can intervene promptly to address the underlying issues and prevent potential falls. This proactive approach aligns with the goal of ensuring the client is free from injury caused by falls. Monitoring for chest pain and elevated low-density lipoprotein levels, postural changes in BP, or mild fever may be important for overall client care but are not directly related to fall prevention.