ATI RN
Maternity and Pediatric Nursing 4th Edition Test Bank Questions
Question 1 of 5
Halfway through the administration of a unit of blood, a client complains of lumbar pain. The nurse should:
Correct Answer: C
Rationale: Lumbar pain during a blood transfusion can be a sign of an adverse reaction, such as a transfusion reaction. Any complaints of pain during a transfusion should not be ignored. In this case, the nurse should first stop the transfusion to prevent any further complications. The client should be assessed promptly for other signs of a transfusion reaction, and appropriate actions should be taken as needed to ensure the client's safety and well-being.
Question 2 of 5
Which of the following complications can occur if a clotted cannula is aggressively flushed?
Correct Answer: A
Rationale: If a clotted cannula is aggressively flushed, there is a risk that the clot may break apart and enter the circulation. This can lead to serious complications such as embolism, where the clot travels through the blood vessels and blocks blood flow to vital organs. It is important to handle clotted cannulas with care to prevent such complications from occurring.
Question 3 of 5
What does a nurse assess postoperatively in a client with a nasal fracture?
Correct Answer: C
Rationale: Postoperatively in a client with a nasal fracture, a nurse would assess for airway obstruction. Nasal fractures can cause swelling, bleeding, and obstruction of the nasal passages, which could potentially compromise the client's ability to breathe. Monitoring for signs of airway compromise, such as difficulty breathing, stridor, or other respiratory distress, is crucial in the postoperative period to ensure prompt intervention if necessary. Assessing for airway patency is a priority to prevent any serious complications related to impaired breathing. While allergic reaction, extreme sense of smell, or stridor may occur in some cases, airway obstruction is the most critical concern that requires immediate attention to maintain the client's respiratory function.
Question 4 of 5
Which of the ff interventions is implemented for a client with empyema?
Correct Answer: D
Rationale: Empyema is a serious infection that requires aggressive treatment with antibiotics. The client must complete the entire course of drug therapy as prescribed by the healthcare provider to ensure that the infection is completely eradicated. Failure to complete the full course of antibiotics can lead to antibiotic resistance and recurrence of the infection. It is crucial to emphasize to the client the importance of adhering to the prescribed treatment regimen to achieve a full recovery and prevent complications.
Question 5 of 5
A patient has end-stage dilated cardiomyopathy. He comes to the emergency department with dyspnea. He says he went to bed and awoke with a feeling of suffocation. He says it was frightening. Which of the ff. responses by the nurse is most appropriate?
Correct Answer: C
Rationale: The most appropriate response by the nurse is option C, "Reclining increases fluid returning to the heart, which builds up fluid in the lungs." In a patient with end-stage dilated cardiomyopathy, reclining position can lead to increased fluid return to the heart due to the failing pump function. This can result in fluid backing up in the lungs, causing symptoms such as dyspnea or feeling of suffocation. By explaining this mechanism to the patient, the nurse can provide valuable information about the condition and the reason for the distressing symptoms experienced by the patient. It also highlights the importance of proper positioning to alleviate symptoms and improve the patient's comfort.