ATI LPN
Immune System Questions Questions
Question 1 of 5
The client in end-stage of renal failure had undergone kidney transplant. Which of the following assessment findings indicate kidney transplant rejection?
Correct Answer: C
Rationale: The correct answer is C. Decreased urinary output and sudden weight gain indicate kidney transplant rejection. Decreased urinary output suggests decreased kidney function, while sudden weight gain can be due to fluid retention caused by rejection. Increased urinary output and normal BUN indicate proper kidney function. High HCT and Hgb levels indicate good oxygen-carrying capacity, ruling out rejection. Decreased urinary output and weight loss are not typical signs of rejection.
Question 2 of 5
The nurse is teaching the parents of a 4-month-old infant about good feeding habits. The nurse emphasizes the importance of holding the baby during feeding and not letting the infant go to sleep with the bottle. Which disorder is associated with propped feedings and going to sleep with the bottle?
Correct Answer: A
Rationale: The correct answer is A: Otitis media. Propped feedings and letting the baby sleep with a bottle can lead to increased risk of otitis media, an ear infection. When a baby is propped up during feeding, there is a greater chance of liquid entering the middle ear through the Eustachian tube, leading to infection. All other choices (B: Aspiration, C: Malocclusion problems, D: Sleeping disorders) are not directly associated with propped feedings and bottle sleeping in infants.
Question 3 of 5
A mother asks when toilet training is most appropriately initiated. What would be the nurse’s best response?
Correct Answer: B
Rationale: The correct answer is B because toilet training should be initiated when the child shows signs of physical and psychological readiness, such as staying dry for longer periods, showing interest in using the toilet, and being able to communicate their needs. This approach ensures a more successful and less stressful toilet training experience for both the child and the parent. Choice A is incorrect because starting toilet training based solely on age may not align with the child's individual readiness. Choice C is incorrect as walking ability does not necessarily indicate readiness for toilet training. Choice D is incorrect because the ability to sit on the potty for a specific time does not guarantee readiness for toilet training.
Question 4 of 5
The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells the nurse that her bandage is 'too wet.' The nurse finds the bandage and bed soaked with blood. The most appropriate initial nursing action is which of the following?
Correct Answer: D
Rationale: The correct initial nursing action is D: Apply direct pressure above catheterization site. This is the correct answer because applying direct pressure above the catheterization site will help control the bleeding and prevent further blood loss. Here is a step-by-step rationale: 1. Direct pressure is the first-line intervention for controlling bleeding. 2. It helps to promote clot formation and stop the bleeding. 3. Placing the child in Trendelenburg position is not indicated and can potentially worsen the situation by increasing blood flow to the site. 4. Applying a new bandage with more pressure can disrupt any clot formation and is not recommended as the first action. 5. Notifying the physician is important but should not be the initial action when dealing with active bleeding.
Question 5 of 5
Which of the following structural defects constitute tetralogy of Fallot?
Correct Answer: A
Rationale: The correct answer is A. In Tetralogy of Fallot, the four structural defects are: pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. Pulmonary stenosis leads to decreased blood flow to the lungs, ventricular septal defect causes mixing of oxygenated and deoxygenated blood, overriding aorta results in blood from both ventricles entering the aorta, and right ventricular hypertrophy occurs due to increased workload in pumping blood through the stenotic pulmonary valve. Choices B, C, and D do not include the correct combination of structural defects seen in Tetralogy of Fallot.