ATI RN
Fluid Maintenance Pediatrics Practice Questions Questions
Question 1 of 5
Patients are at risk for overwhelming postsplenectomy infection (OPSI) following splenectomy. Which of the ff. symptoms alerts the nurse to this possibility?
Correct Answer: D
Rationale: Patients who have undergone splenectomy are at risk for overwhelming postsplenectomy infection (OPSI) due to the absence of a functioning spleen, which is important in fighting certain types of infections, especially those caused by encapsulated bacteria such as Streptococcus pneumoniae. Symptoms of OPSI can include fever, chills, weakness, and rapid breathing. Fever is a significant sign that alerts the nurse to the possibility of OPSI in a post-splenectomy patient, as it may indicate an infection that the body is struggling to fight without the spleen's immune support. This is a crucial symptom to monitor and act upon promptly to prevent serious complications in these individuals.
Question 2 of 5
A client has squamous cell cancer of the right lung that has metastasized to the brain. In addition to chemotherapy for lung cancer, the physician prescribes lomustine (CeeNU), 100 mg/m2 as a single dose, to treat the brain metastasis. What are the major administration and excretion routes of lomustine?
Correct Answer: B
Rationale: Lomustine (CeeNU) is typically administered intravenously (I.V.), making choice B the correct administration route. Lomustine is metabolized in the liver and excreted primarily through the kidneys via urine, which accounts for its urinary excretion. Therefore, the major administration route for lomustine is intravenous (I.V.) and the major excretion route is urinary.
Question 3 of 5
On a visit to the gynecologist, a client complains of urinary frequency, pelvic discomfort, and weight loss. After a complete physical examination, blood studies, and a pelvic examination with a Papanicolaou test, the physician diagnoses stage IV ovarian cancer. The nurse expects to prepare the client for which initial treatment?
Correct Answer: C
Rationale: In the case of stage IV ovarian cancer, initial treatment typically involves major surgery, known as cytoreductive surgery or debulking surgery. The goal of this surgery is to remove as much of the tumor burden as possible from the abdomen and pelvis. By reducing the size of the tumor, the effectiveness of subsequent treatments such as chemotherapy can be enhanced. Surgery may also involve the removal of the uterus, ovaries, fallopian tubes, and surrounding tissue. Radiation therapy or chemotherapy may be used after surgery to further target any remaining cancer cells. However, major surgery is often the first step in the management of advanced ovarian cancer.
Question 4 of 5
The nurse is instructing a premenopausal woman about breast self-examination. The nurse should tell the client to do her self-examination:
Correct Answer: C
Rationale: The nurse should advise the premenopausal woman to perform her breast self-examination on the same day each month. Regular monthly self-examination helps the woman become familiar with the normal texture and appearance of her breasts, making it easier to detect any changes or abnormalities that may indicate a problem. Performing the examination on the same day each month helps ensure consistency in timing and facilitates the woman to establish a routine for self-examination. This consistent approach increases the likelihood of detecting any changes early, which is crucial for timely medical evaluation and intervention if needed.
Question 5 of 5
Which nursing intervention is most appropriate for a client with multiple myeloma?
Correct Answer: D
Rationale: One of the primary concerns in clients with multiple myeloma is bone damage and fractures due to weakened bones caused by the disease. Preventing bone injury is a crucial nursing intervention to focus on for these clients. Measures to prevent bone injury include implementing fall precautions, encouraging safe mobility, providing supportive devices such as walkers or canes, and educating the client on strategies to prevent falls and fractures. Additionally, pain management and regular assessment for signs of bone damage are essential in caring for clients with multiple myeloma. Other interventions such as monitoring respiratory status, balancing rest and activity, and restricting fluid intake may be important in certain situations for these clients but preventing bone injury takes precedence due to the increased risk of skeletal complications associated with multiple myeloma.