ATI LPN
Immune System Questions Questions
Question 1 of 5
The nurse is administering packed red blood cells to a child with sickle cell disease (SCD). The nurse is monitoring for a transfusion reaction and knows it is most likely to occur during which time frame?
Correct Answer: B
Rationale: The correct answer is B: Within the first 20 minutes of administration of the transfusion. During the initial stage of transfusion, reactions are most likely to occur due to rapid infusion of blood. This is when the nurse should closely monitor the child for signs of transfusion reactions such as fever, chills, rash, or shortness of breath. Reactions can be severe and life-threatening, so early detection is crucial. Choices A, C, and D are incorrect because reactions are most likely to occur at the beginning of the transfusion due to immediate immune responses, rather than hours later, at the end of the transfusion, or not at all.
Question 2 of 5
A child is diagnosed with thrombocytopenia secondary to chemotherapy treatments. Which action by the nurse is not appropriate?
Correct Answer: A
Rationale: The correct answer is A: Administer intramuscular injections (IM). In a child with thrombocytopenia, the platelet count is low, leading to an increased risk of bleeding. Administering IM injections can cause bleeding at the injection site due to the potential trauma to blood vessels. Performing oral hygiene (B), monitoring intake and output (C), and using palpation as a component of assessment (D) are appropriate actions that do not pose a significant risk of bleeding in a child with thrombocytopenia. It is crucial to prioritize interventions that minimize the risk of bleeding complications in this scenario.
Question 3 of 5
Which of the following would be an appropriate nursing diagnosis for a child who is receiving chemotherapy?
Correct Answer: D
Rationale: The correct answer is D: Impaired oral mucous membrane. This is an appropriate nursing diagnosis for a child receiving chemotherapy because chemotherapy often causes mucositis, leading to pain, difficulty eating, and an increased risk of infection in the oral cavity. Nurses need to assess and monitor oral mucous membranes closely in these patients. Incorrect choices: A: Ineffective breathing pattern - Not directly related to chemotherapy in this scenario. B: Constipation - Not typically a common issue specifically related to chemotherapy. C: Impaired skin integrity - Not directly related to the side effects of chemotherapy on oral mucous membranes.
Question 4 of 5
A child who has nephrotic syndrome is admitted to the pediatric unit. Which of the following should the nurse expect to find? (Select one that does not apply.)
Correct Answer: A
Rationale: The correct answer is A: Decreased urine specific gravity. In nephrotic syndrome, there is increased protein loss in the urine, leading to proteinuria and hypoalbuminemia. This results in a decrease in colloid osmotic pressure, causing fluid to leak into the interstitial spaces, leading to edema. Hyperlipidemia occurs due to the liver's response to low serum albumin levels. However, urine specific gravity is typically normal or even increased due to the concentrated urine caused by the loss of proteins and other solutes. Therefore, the nurse should not expect to find decreased urine specific gravity in a child with nephrotic syndrome.
Question 5 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.