ATI RN
Burns Pediatric Primary Care 7th Edition Test Bank Questions
Question 1 of 5
The nursing staff has a team conference on AIDS and discusses the routes of transmission of the human immunodeficiency virus (HSV). The discussion reveals that an individual has no risk of exposure to HIV when that individual;
Correct Answer: C
Rationale: The correct answer is C. An individual has no risk of exposure to HIV when they limit sexual contact to those without HIV antibodies. This is because HIV is primarily transmitted through contact with body fluids such as blood, semen, vaginal fluids, and breast milk of an infected person. If an individual only engages in sexual activities with people who do not have HIV antibodies, the risk of exposure to the virus is significantly reduced. It is important to note that although this reduces the risk, it does not completely eliminate it, as there is still a chance of transmission through other means such as sharing needles or from mother to child during pregnancy, childbirth, or breastfeeding.
Question 2 of 5
A 50-year-old African American patient is diagnosed with anemia. Where can the nurse assess for pallor?
Correct Answer: D
Rationale: When assessing for pallor in a patient with anemia, the nurse should specifically look at the conjunctivae (the membranes that cover the white part of the eyes). In individuals with anemia, the lack of red blood cells can result in paleness in the conjunctivae, which can be observed as a pale or whitish color. This area is especially useful for assessing pallor in individuals with darker skin tones, such as African Americans, where pallor may be less noticeable on other areas of the body.
Question 3 of 5
For a client with polycythemia vera, how can the nurse help decrease the risk for thrombus formation?
Correct Answer: B
Rationale: For a client with polycythemia vera, there is an increased risk for thrombus formation due to the increased viscosity of the blood. Wearing thromboembolic stockings or support hose can help promote circulation, prevent stasis, and reduce the risk of thrombus formation. Compression stockings provide external pressure to the legs, which helps prevent blood from pooling and clotting. This intervention is commonly recommended for patients at risk for thrombus formation to improve blood flow in the lower extremities and reduce the risk of deep vein thrombosis (DVT) and pulmonary embolism.
Question 4 of 5
An adult is diagnosed with disseminated intravascular coagulation. The nurse should identify that the client is at risk for which of the following nursing diagnosis?
Correct Answer: C
Rationale: Disseminated intravascular coagulation (DIC) is a serious condition that involves widespread activation of coagulation leading to microthrombi formation in blood vessels throughout the body. This process can lead to consumption of clotting factors and platelets, causing both bleeding and thrombosis. In the context of DIC, there is a risk for altered tissue perfusion due to the combination of bleeding and microthrombi formation, which can impair blood flow to vital organs and tissues. This condition can ultimately result in organ dysfunction and failure, making it a significant concern in the care of a client with DIC. Therefore, the correct nursing diagnosis for a client with DIC is alteration in tissue perfusion related to bleeding and diminished blood flow.
Question 5 of 5
What is the most important postoperative instruction the nurse must give a client who has just returned from the operating room after receiving a subarachnoid block?
Correct Answer: D
Rationale: After receiving a subarachnoid block, the client may experience a sudden drop in blood pressure that can lead to complications such as dizziness or fainting upon standing. Therefore, it is crucial for the client to remain in a supine position for the duration specified by the physician to allow for proper monitoring and management of any potential postoperative complications. This instruction helps prevent the occurrence of hypotension and other adverse effects by allowing adequate time for the block to wear off and for the body to adjust to changes in blood pressure. It also ensures the safety and well-being of the client during the immediate postoperative period.