ATI LPN
Questions About the Immune System Questions
Question 1 of 5
The term petechiae refers to:
Correct Answer: C
Rationale: The term petechiae refers to small red or purple spots on the skin caused by broken blood vessels. These spots are typically pinpoint in size and do not raise above the skin surface. The correct answer is C, as it accurately describes the characteristic appearance of petechiae. Option A is incorrect as petechiae are not large or raised. Option B is incorrect as petechiae are not indicative of an infection. Option D is incorrect as petechiae are not related to deep vein thrombosis.
Question 2 of 5
A child with hemophilia plans on participating in a bicycling club. The nurse should recommend the child
Correct Answer: B
Rationale: The correct answer is B - Wear kneepads, elbow pads, and a helmet while bicycling. This recommendation is crucial for the safety of the child with hemophilia as it helps prevent injuries and potential bleeding episodes in case of falls. Kneepads and elbow pads provide extra protection to vulnerable joints, while a helmet protects the head from trauma. This allows the child to engage in physical activities like bicycling while minimizing the risk of bleeding complications. Choice A is incorrect because swimming may also pose a risk of injury, and protective gear is still necessary. Choice C is incorrect as it limits the child's participation and does not address safety concerns. Choice D is incorrect as it unnecessarily restricts the child's social engagement and physical activity without providing an alternative solution.
Question 3 of 5
A child undergoing chemotherapy treatment has the following laboratory values: Absolute neutrophil count of 400 mm3; Hematocrit (HCT) 32%; Platelet Count 150,000 per microliter; Serum Potassium 4.5 mmol/L. The pediatric nurse correctly determines that the child is at risk for:
Correct Answer: D
Rationale: The correct answer is D: Infection. A low Absolute neutrophil count indicates neutropenia, which increases the risk of infection due to decreased ability to fight off pathogens. Hematocrit and Platelet Count are within normal range, so anemia and bleeding are not immediate concerns. Serum Potassium level is normal, ruling out cardiac arrest risk. Therefore, the child is at highest risk for infection due to neutropenia.
Question 4 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 5 of 5
A nurse is caring for a child who is postoperative following surgical removal of a Wilms’ tumor. Which of the following assessments is an indication to continue NPO status?
Correct Answer: C
Rationale: The correct answer is C: Absent bowel sounds. Following surgical removal of a Wilms' tumor, absent bowel sounds indicate potential postoperative ileus, which can lead to complications if oral intake is resumed prematurely. Absence of bowel sounds may suggest a lack of peristalsis and require continued NPO status to prevent complications. A: Abdominal girth 1 cm larger than yesterday may indicate fluid retention or bloating, but it does not specifically warrant continued NPO status. B: Report of pain at the operative site is expected postoperatively and does not necessarily require NPO status. D: Passing of flatus every 30 min indicates bowel function and is a positive sign for resuming oral intake.