ATI RN
Maternity and Pediatric Nursing 4th Edition Test Bank Questions
Question 1 of 5
Hepatitis C virus infection is a risk factor for which of the following malignancy?
Correct Answer: B
Rationale: Hepatitis C is a known risk factor for splenic lymphoma and other B-cell lymphoproliferative disorders.
Question 2 of 5
A client with advanced liver cancer is scheduled for chemotherapy. As part of the chemotherapy regimen, the nurse expects the physician to prescribe:
Correct Answer: B
Rationale: Fluorouracil (5-FU) is a commonly used chemotherapy drug for various cancers, including of the liver. It is often used to treat advanced liver cancer as part of a chemotherapy regimen. 5-FU works by interfering with the synthesis of DNA and RNA in cancer cells, leading to their death.
Question 3 of 5
A child is to receive a blood transfusion, if an allergic reaction to the blood occurs, the nurse's first intervention should be:
Correct Answer: C
Rationale: In the scenario of a child experiencing an allergic reaction during a blood transfusion, the nurse's first intervention should always be to stop the blood immediately. This is crucial to prevent further complications and adverse reactions in the child. Pausing the transfusion allows for assessment of the allergic reaction's severity, immediate treatment initiation, and alerting the healthcare team for further management. Relieving symptoms with antihistamines or slowing the flow rate would not address the primary concern of stopping the allergen from entering the child's system. Therefore, stopping the blood immediately is the most appropriate and urgent action to take in this situation.
Question 4 of 5
The client with myasthenia gravis has become increasingly weaker. The physician prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium (Tensilon) is administered. Which of the following would indicate that the client is in cholinergic crisis?
Correct Answer: D
Rationale: Administering edrophonium (Tensilon) to a client with myasthenia gravis helps differentiate between cholinergic crisis and myasthenic crisis. In cholinergic crisis, which is caused by excessive acetylcholine levels due to an overdose of anticholinesterase medications, the client may experience a temporary worsening of symptoms such as muscle weakness, respiratory distress, and other cholinergic effects. This temporary worsening is due to the increase in acetylcholine levels, leading to overstimulation of nicotinic and muscarinic receptors. On the other hand, in myasthenic crisis, which is caused by insufficient acetylcholine at the neuromuscular junction, administering edrophonium would lead to an improvement in muscle weakness. Therefore, if the client experiences a temporary worsening of symptoms after receiving edrophonium, it indicates cholinergic crisis.
Question 5 of 5
A client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume?
Correct Answer: B
Rationale: Increased urine osmolarity would best support the nursing diagnosis of Deficient fluid volume in a client with hyperglycemia. Hyperglycemia can lead to osmotic diuresis, where the body excretes excessive amounts of water to help eliminate glucose. This results in concentrated urine with a higher osmolarity. A high urine osmolarity indicates that the kidneys are conserving water due to decreased fluid volume in the body, supporting the diagnosis of Deficient fluid volume. The other assessment findings (cool, clammy skin, distended neck veins, serum sodium level) are not specific to the diagnosis of Deficient fluid volume in this context.