ATI RN
Cardiovascular Conditions Pediatrics Test Bank Questions Free Nursing Questions
Question 1 of 5
To reduce the risk for pulmonary complications for a client with Amyotrophic Lateral Sclerosis (ALS), what interventions should the nurse implement?
Correct Answer: C
Rationale: In the context of a client with Amyotrophic Lateral Sclerosis (ALS), the correct intervention to reduce the risk for pulmonary complications is to teach the client breathing exercises (Option C). ALS is a progressive neurodegenerative disease that affects motor neurons, leading to muscle weakness and respiratory compromise. Teaching the client breathing exercises can help maintain lung function, improve respiratory muscle strength, and prevent complications such as pneumonia or respiratory failure. Initiating passive range of motion exercises (Option A) may be beneficial for maintaining joint mobility and preventing contractures in ALS patients but does not directly address pulmonary complications. Establishing a regular bladder routine (Option B) is important for managing urinary issues in ALS but is not directly related to reducing pulmonary complications. Performing chest physiotherapy (Option D) may help with secretion clearance but does not address the overall respiratory muscle weakness seen in ALS. Educationally, it is crucial for nurses to understand the specific needs of clients with ALS, especially regarding respiratory care. Teaching breathing exercises empowers the client to take an active role in maintaining their respiratory function and quality of life. Nurses play a key role in educating clients with ALS about self-care strategies to optimize their respiratory health and prevent complications.
Question 2 of 5
An older client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement?
Correct Answer: C
Rationale: In this scenario, the correct answer is C) Provide an eye shield to be worn while sleeping. This intervention is essential following cataract extraction and lens implant surgery to protect the eye from accidental trauma during sleep. The eye shield ensures that the eye is shielded from inadvertent rubbing or pressure, which could compromise the surgical site and lead to complications. Option A) Teach a family member to administer eye drops is incorrect because while eye drops may be part of the postoperative care, ensuring protection during sleep with an eye shield takes precedence to prevent injury. Option B) Encourage deep breathing and coughing exercises is incorrect as this intervention is more relevant for respiratory conditions or surgeries that involve the chest, not for eye surgeries like cataract extraction. Option D) Obtain vital signs every 2 hours during hospitalization is incorrect as this is not a specific intervention related to eye surgery postoperative care. Monitoring vital signs is important in general patient care but is not directly related to protecting the eye after cataract surgery. In an educational context, it is crucial for nursing students to understand the specific postoperative care requirements for different surgical procedures. Emphasizing the rationale behind each intervention helps students develop critical thinking skills in prioritizing patient care and understanding the rationale for each nursing action in providing safe and effective postoperative care.
Question 3 of 5
The nurse is assessing clients in an outpatient diabetic clinic. Which entry provides the best evidence that the client is adhering to the prescribed diabetic regimen?
Correct Answer: A
Rationale: In this scenario, option A, "Hemoglobin A1C of 6.2%," provides the best evidence that the client is adhering to the prescribed diabetic regimen. Hemoglobin A1C is a valuable indicator of long-term glucose control, reflecting average blood glucose levels over the past 2-3 months. A level of 6.2% indicates good glycemic control and suggests that the client has been consistently following their prescribed diabetic regimen. Option B, "Fasting blood glucose of 130 mg/dL," is a single point-in-time measurement and may not accurately represent the client's overall glucose control. It can fluctuate throughout the day based on various factors. Option C, "Positive urine ketones," indicates the presence of ketones in the urine, which typically signifies poor diabetes management and potential complications like diabetic ketoacidosis. It is not a reliable indicator of adherence to the prescribed regimen. Option D, "Self-reported daily blood glucose monitoring," while a positive behavior, relies on self-reporting, which may not always be accurate. Objective measures like A1C provide more reliable evidence of adherence. Educationally, it is crucial for nurses to understand the significance of different parameters in assessing diabetic control. Teaching patients the importance of regular monitoring, medication adherence, and lifestyle modifications can help improve outcomes and prevent complications in pediatric patients with diabetes.
Question 4 of 5
A client returns to the unit following a suprapubic prostatectomy. He has a three-way catheter in place with a continuous bladder irrigation infusing. Which assessment finding warrants immediate intervention by the nurse?
Correct Answer: D
Rationale: In this scenario, the correct answer is option D: Urine leaking around the meatus. This finding warrants immediate intervention by the nurse because it indicates a potential complication such as urinary leakage, which could lead to infection or disruption of the surgical site. Addressing this issue promptly is crucial to prevent further complications and ensure the client's recovery. Option A (True urinary output of 50ml/hr) is not the most concerning finding in this context. While monitoring urinary output is important postoperatively, a consistent output of 50ml/hr may not immediately indicate a critical issue. Option B (Lower abdominal tenderness) is a common postoperative finding and may be expected after a suprapubic prostatectomy. While it should be monitored, it does not require immediate intervention unless it is severe or accompanied by other concerning symptoms. Option C (Blood urine output with clots) is also a serious finding that should be addressed, but in this case, the presence of clots alone may not always warrant immediate intervention unless it is causing obstruction or significant bleeding. This scenario is crucial for nursing students to understand the immediate postoperative assessment of clients undergoing genitourinary surgeries. Recognizing and prioritizing critical assessment findings can help prevent complications and promote optimal patient outcomes in clinical practice.
Question 5 of 5
A male client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about the dietary restriction he should follow. In discussing fluid intake, the nurse should include which type of fluid limitation?
Correct Answer: C
Rationale: The correct answer is C) Tea and hot chocolate. When a client is recovering from urinary tract calculi, especially if they were calcium oxalate stones, they should limit their intake of foods and drinks high in oxalates, such as tea and hot chocolate. Oxalates can contribute to the formation of these types of stones, so restricting them can help prevent recurrence. Option A, low-sodium soups, is not directly related to urinary tract calculi, so it is not the most appropriate choice. Option B, overall fluid intake, should not be limited as adequate hydration is important in preventing stone formation. Option D, citrus fruit juices, should not be restricted unless the client has a specific sensitivity to them. In an educational context, it is crucial for nurses to provide accurate and relevant dietary information to clients recovering from urinary tract calculi to help prevent recurrence and promote optimal health. Understanding the impact of specific foods and fluids on the formation of stones is essential in guiding dietary recommendations.