ATI RN
Burns Pediatric Primary Care 7th Edition Test Bank Questions
Question 1 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 2 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 3 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.
Question 4 of 5
Which of the ff actions should the nurse perform to monitor for electrolyte imbalances and dehydration in a client with a neurologic deficit?
Correct Answer: A
Rationale: Monitoring intake and output is essential in assessing for electrolyte imbalances and dehydration in a client with a neurologic deficit. Unlike options B, C, and D, measuring intake and output provides direct information on the client's fluid balance and kidney function. Electrolyte imbalances can lead to neurological complications and alterations in mental status, making it crucial to keep track of the amounts of fluids ingested and excreted by the client. Additionally, dehydration can exacerbate neurological deficits, so monitoring intake and output can help prevent this complication.
Question 5 of 5
The nurse is preparing an intravenous infusion of phenytoin (Dilantin) as prescribed by the physician for the client with seizures. Which of the following solutions will the nurse plan to use to dilute this medication?
Correct Answer: C
Rationale: Phenytoin (Dilantin) is known to be incompatible with dextrose solutions (such as dextrose 5% or dextrose 5% and half-normal saline). Therefore, the nurse would plan to use normal saline solution to dilute phenytoin in order to ensure medication effectiveness and prevent any potential adverse reactions. Lactated Ringer's solution is not commonly used for diluting phenytoin as normal saline solution is the preferred choice due to compatibility considerations.