ATI LPN
Questions About the Immune System Questions
Question 1 of 5
The nurse is caring for a child with disseminated intravascular coagulation (DIC). Which is a priority intervention for this child?
Correct Answer: B
Rationale: The correct answer is B: Maintenance of skin integrity. In DIC, widespread clotting leads to depletion of clotting factors and platelets, causing bleeding. Maintaining skin integrity helps prevent skin breakdown and potential bleeding complications. Frequent ambulation (A) is not a priority as it may increase the risk of bleeding. Radiograph procedures (C) are not a priority in the immediate care of DIC. Monitoring fluid restriction (D) is not the priority as maintaining skin integrity takes precedence in DIC management.
Question 2 of 5
A child with a brain tumor is admitted to the pediatric intensive care unit (PICU) after brain surgery to remove the tumor. Which postoperative order would the nurse question?
Correct Answer: B
Rationale: The correct answer is B: Sodium levels every 24 hours. The nurse would question this order because monitoring sodium levels every 24 hours is not usually necessary postoperatively for a child with a brain tumor. Brain surgery and tumor removal may not specifically impact sodium levels, making this monitoring less relevant. Antibiotics are commonly prescribed after brain surgery to prevent infection (A), anticonvulsants may be needed to prevent seizures (C), and monitoring intake and output is essential for assessing hydration status and kidney function (D). Monitoring sodium levels every 24 hours is not a standard postoperative practice for this situation.
Question 3 of 5
A child is being treated for strep throat. The nurse tells the parent to report any abrupt onset of midabdominal pain along with malaise, irritability and fever. The nurse is teaching the parent signs of:
Correct Answer: B
Rationale: The correct answer is B: Acute post-streptococcal glomerulonephritis. This condition is a possible complication of strep throat caused by an immune response to the streptococcal infection affecting the glomeruli of the kidneys. The signs mentioned by the nurse (abrupt onset of midabdominal pain, malaise, irritability, and fever) are indicative of this condition. Sodium retention (choice A) is not associated with these specific signs. Hemolytic-uremic syndrome (choice C) typically presents with bloody diarrhea and kidney injury, not midabdominal pain. Renal insufficiency (choice D) may present with various symptoms but does not typically include midabdominal pain as a prominent sign.
Question 4 of 5
A child has been diagnosed with stage 3 chronic kidney disease (CKD). The nurse would question the medical order for:
Correct Answer: D
Rationale: The correct answer is D, Intravenous pyelogram with contrast to visualize kidneys. In stage 3 CKD, the kidneys are moderately damaged, making them vulnerable to further harm from contrast dye. The use of contrast dye can worsen kidney function and potentially lead to acute kidney injury. The other options (ACE inhibitor, erythropoietin therapy, iron replacement therapy, long-acting insulin) are appropriate treatments for complications of CKD and aim to manage blood pressure, anemia, and blood sugar levels, respectively. However, the use of contrast dye in this scenario poses a risk to the already compromised kidneys and should be avoided.
Question 5 of 5
An infant is born with an esophageal atresia and tracheoesophageal fistula. Which preoperative nursing diagnosis is the priority for this infant?
Correct Answer: A
Rationale: The correct answer is A: Risk for Aspiration Related to Regurgitation. This is the priority because the infant with esophageal atresia and tracheoesophageal fistula is at high risk for aspiration due to the abnormal connection between the esophagus and trachea. Aspiration can lead to serious complications such as pneumonia and respiratory distress. Addressing this risk is crucial for the infant's safety and well-being. Choice B (Acute Pain) is not the priority as aspiration poses a more immediate threat to the infant's health. Choice C (Ineffective Infant Feeding Pattern) is important but addressing the risk of aspiration takes precedence. Choice D (Ineffective Tissue Perfusion) is not directly related to the immediate danger of aspiration in this case. Prioritizing the prevention of aspiration is essential for the infant's safety and effective care.