ATI RN
Burns Pediatric Primary Care 7th Edition Test Bank Questions
Question 1 of 5
Pulmonary edema is characterized by:
Correct Answer: C
Rationale: Pulmonary edema is characterized by increased hydrostatic pressure in the pulmonary capillaries and a rise in pulmonary venous pressure, which leads to fluid leaking out of the pulmonary capillaries and into the alveoli. This results in elevated left ventricular end-diastolic pressure, which is a key characteristic of pulmonary edema. Therefore, all of the above alterations (increased hydrostatic pressure, a rise in pulmonary venous pressure, and elevated left ventricular end-diastolic pressure) are seen in pulmonary edema.
Question 2 of 5
The nurse understands that which of the ff. is a side effect most likely to be reported by patients receiving enalapril maleate (Vasotec)?
Correct Answer: C
Rationale: The most common side effect reported by patients receiving enalapril maleate (Vasotec) is a persistent dry cough. This cough is due to the medication's effect on bradykinin levels in the body, leading to irritation of the respiratory tract and causing the cough. While other side effects such as diarrhea and heartburn may occur, cough is the most frequently reported side effect associated with enalapril maleate. Acne is not a commonly reported side effect of this medication.
Question 3 of 5
Which of the following BP changes alerts the nurse to increasing ICP, and should be reported immediately?
Correct Answer: B
Rationale: Widening pulse pressure is indicative of increasing intracranial pressure (ICP) and must be reported immediately. Pulse pressure is calculated by subtracting the diastolic blood pressure from the systolic blood pressure. An increasing pulse pressure can suggest a rise in ICP due to factors like cerebral edema or hemorrhage. This change indicates increased pressure exerted on blood vessels within the brain, potentially leading to serious consequences like brain herniation. Thus, recognizing and promptly reporting a widening pulse pressure is crucial to prevent further complications and enable appropriate interventions for the patient.
Question 4 of 5
Which of the ff nursing interventions is taken as a precautionary measure if shock develops when a client with a spinal cord injury is hospitalized?
Correct Answer: A
Rationale: In a hospital setting, if shock develops in a client with a spinal cord injury, one of the initial nursing interventions as a precautionary measure is to establish intravenous access by inserting an IV line. This is important for administering fluids, medications, and blood products promptly to help stabilize the client's condition. IV access is crucial in managing shock to ensure proper fluid resuscitation and support the circulatory system to maintain adequate perfusion to vital organs. It also allows for continuous monitoring of the client's hemodynamic status, electrolyte levels, and responses to interventions. Therefore, inserting an IV line is a critical nursing intervention in addressing shock in clients with spinal cord injuries to promote timely and effective management.
Question 5 of 5
The nurse assesses the motor functions during a neurologic examination of a client. Which of the ff steps will help the nurse perform the examination effectively? Choose all that apply
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.