ATI RN
NCLEX RN Pediatric Questions Questions
Question 1 of 5
Mr. Mariano was on his way home from a party. Apparently, he got drunk and lost his balance and suffered a vehicular accident. Upon arrival at the hospital, the nurse noticed that his only injury is an open fracture of the left humerus. Which assessment finding by the nurse is critical?
Correct Answer: A
Rationale: In this situation where Mr. Mariano has an open fracture of the left humerus, the nurse's critical assessment finding should be the status of the client's tetanus immunization. An open fracture poses a risk of infection, and tetanus is a concern due to the potential exposure to bacteria from the environment causing tetanus. Tetanus is a serious bacterial infection that affects the nervous system and can be fatal if not treated promptly. Knowing the client's tetanus immunization status will help determine the need for a tetanus booster to prevent this potentially life-threatening infection. Blood alcohol level, support systems at home, and voiding time are important assessments as well, but in the case of an open fracture, the priority is to assess the risk of tetanus infection.
Question 2 of 5
A client seeks medical evaluation for fatigue, night sweats, and a 20-lb weight loss in 6 weeks. To confirm that the client has been infected with the human immunodeficiency virus (HIV), the nurse expects the physician to order:
Correct Answer: D
Rationale: The confirmatory test for HIV infection is a Western blot test. However, before a Western blot test is conducted, an initial screening test with high sensitivity, such as the enzyme-linked immunosorbent assay (ELISA), is typically performed. ELISA is used to detect the presence of HIV antibodies in the blood. If the ELISA test is positive, a Western blot test is then performed to confirm the presence of specific HIV antibodies. The Western blot test is a more specific test for HIV antibodies and is used to confirm the diagnosis. Therefore, in this case, the physician would most likely order a Western blot test following a positive ELISA test to confirm the client's HIV infection.
Question 3 of 5
Nurse Lina gives discharge instructions to Aling Maria, who is experiencing an exacerbation of COPD because of an upper respiratory tract infection, regarding her diet at home. Which of the following food choices would be appropriate?
Correct Answer: D
Rationale: A patient experiencing an exacerbation of COPD, especially due to an infection, requires a diet that is high in calories and protein. This is because during exacerbations, the body's energy requirements increase due to increased work of breathing and inflammation. High-calorie intake helps provide the necessary energy for breathing and healing. Additionally, a high-protein diet is important for maintaining respiratory and skeletal muscle strength, which can be affected during exacerbations of COPD. Therefore, a high-calorie high-protein diet would be most appropriate for Aling Maria to support her recovery and overall health during this period.
Question 4 of 5
Which is an accurate description of a Kasai procedure?
Correct Answer: A
Rationale: The Kasai procedure is a palliative surgery for biliary atresia that helps restore bile flow and delays the need for liver transplantation.
Question 5 of 5
Which of the following would the nurse teach the patient is the most common site for ear infections?
Correct Answer: B
Rationale: The most common site for ear infections is the middle ear. This area is prone to infections, especially in children, due to the Eustachian tube being shorter and more horizontal compared to adults. The middle ear is connected to the upper respiratory tract, allowing bacteria or viruses to easily travel and cause infections in this area. Symptoms of a middle ear infection include ear pain, fluid buildup, and possible hearing loss. Treatment may involve antibiotics and pain relief medications, and in some cases, surgical intervention may be necessary to drain the fluid.