ATI RN
Introduction to Maternity and Pediatric Nursing Test Bank Questions
Question 1 of 5
The nurse is caring for a school-age child who has had a cardiac catheterization. The child tells the nurse that the bandage is "too wet." The nurse finds the bandage and bed soaked with blood. What is the priority nursing action?
Correct Answer: D
Rationale: The priority nursing action in this situation is to apply direct pressure above the catheterization site to control the bleeding. This is important to prevent excessive blood loss and ensure the child's safety. The nurse should quickly address the issue of the soaked bandage and bed by applying direct pressure to the catheterization site to stop the bleeding. Once bleeding is controlled, the nurse should then notify the physician for further evaluation and treatment. Placing the child in Trendelenburg position is not necessary in this scenario, as the immediate focus should be on controlling the bleeding.
Question 2 of 5
A preschool child is scheduled for an echocardiogram. Parents ask the nurse whether they can hold the child during the procedure. The nurse should answer with which response?
Correct Answer: A
Rationale: The correct response is that "You will be able to hold your child during the procedure." It is common for parents to be allowed to hold their child during an echocardiogram to provide comfort and reassurance. This can help the child stay calm and cooperative during the procedure. Holding the child can also create a familiar and secure environment, making it easier for the healthcare provider to perform the echocardiogram successfully.
Question 3 of 5
A patient who has just had a TURP asks his nurse to explain why he has to have the bladder irrigation because it seems to increase his pain. Which of the following explanations by the nurse is best?
Correct Answer: C
Rationale: The best explanation for the patient is option C, which states, "The irrigation is needed to keep the catheter from becoming occluded by blood clots." After a transurethral resection of the prostate (TURP), it is common for the patient to have some bleeding in the bladder. Bladder irrigation is done to prevent blood clots from forming and blocking the catheter. Keeping the catheter patent is important to ensure proper drainage of urine and prevent complications such as urinary retention. While the other options are related to potential reasons for bladder irrigation, option C directly addresses the immediate concern of preventing catheter occlusion by blood clots post-TURP surgery.
Question 4 of 5
A patient has cloudy penile discharge. For which additional symptoms of urethritis should the nurse assess?
Correct Answer: C
Rationale: Cloudy penile discharge is a common symptom of urethritis, which is inflammation of the urethra usually caused by an infection, such as a sexually transmitted infection (STI) like gonorrhea or chlamydia. Painful and frequent urination are also classic symptoms of urethritis. Painful urination, or dysuria, may occur due to the irritation and inflammation of the urethra. Frequency of urination can be a result of the body's response to the infection or inflammation. Therefore, assessing for these additional symptoms helps in confirming the diagnosis of urethritis and determining the appropriate treatment for the patient.
Question 5 of 5
A patient is hemorrhaging from multiple trauma sites. The nurse expects that compensatory mechanisms associated with hypovolemia would cause all of the following symptoms except:
Correct Answer: A
Rationale: In a patient experiencing hemorrhage from multiple trauma sites leading to hypovolemia, compensatory mechanisms typically include an increase in heart rate (tachycardia), a decrease in urine output (oliguria), and an increase in respiratory rate (tachypnea). These mechanisms are the body's way of trying to maintain vital organ perfusion in the setting of decreased blood volume. However, hypertension is not typically seen in the setting of hypovolemia. In fact, blood pressure tends to decrease as a result of reduced circulating volume.