ATI RN
Pediatric Cardiovascular Disorders Nursing Questions
Question 1 of 5
Two days after a nephrectomy, the client reports abdominal pressure and nausea, which assessment should the nurse implement?
Correct Answer: D
Rationale: In this scenario, the correct answer is D) Auscultate bowel sounds. Following a nephrectomy, abdominal pressure and nausea could indicate a paralytic ileus or bowel obstruction, which are potential postoperative complications. Auscultating bowel sounds is essential to assess for the presence or absence of bowel motility and potential blockages. Option A) Palpating the abdomen may exacerbate any potential complications, such as causing discomfort or rupturing a sensitive area post-surgery. It is not the best initial assessment for this situation. Option B) Measuring hourly urine output is important in monitoring kidney function post-nephrectomy but is not directly related to the presenting symptoms of abdominal pressure and nausea. Option C) Ambulating the client in the hallway may be beneficial for general postoperative recovery but is not the priority in this situation where abdominal symptoms need immediate assessment. Educationally, this question highlights the importance of recognizing potential postoperative complications in patients who have undergone nephrectomy. It emphasizes the need for thorough assessment skills and prioritizing assessments based on the client's symptoms to provide timely and appropriate care.
Question 2 of 5
A healthcare worker with no known exposure to tuberculosis has received a Mantoux tuberculosis skin test. The nurse's assessment of the test after 62 hours indicates 5 mm of erythema without induration. What is the best initial nursing action?
Correct Answer: A
Rationale: The best initial nursing action in this scenario is to choose option A) Document negative results in the client's medical record. This is the correct choice because a Mantoux tuberculosis skin test showing 5 mm of erythema without induration after 62 hours is considered negative for tuberculosis infection. It is crucial for healthcare workers to have accurate documentation of test results in the medical record to ensure proper monitoring and follow-up. Option B) Repeat the test immediately on the opposite forearm is not necessary in this case as the initial test result is already negative. Repeating the test without a valid reason can lead to unnecessary discomfort for the healthcare worker and is not supported by evidence-based practice. Option C) Notify the healthcare provider for further evaluation is also not warranted in this situation as the test result is negative. Contacting the healthcare provider without a valid reason can lead to unnecessary burden on the provider and may result in inappropriate follow-up procedures. Option D) Schedule the worker for a chest X-ray is not indicated based on the negative Mantoux test result. Chest X-rays are typically ordered when there are signs and symptoms suggestive of active tuberculosis, which is not the case here. In an educational context, understanding the interpretation of diagnostic tests like the Mantoux test is crucial for nurses working in various clinical settings. It is essential for nurses to be able to accurately interpret test results, document findings appropriately, and follow evidence-based guidelines to provide optimal care for their patients.
Question 3 of 5
A client with Guillain-Barre syndrome has paralysis of all extremities and requires mechanical ventilation. The nurse observes that the client is not blinking. Which action should the nurse implement?
Correct Answer: A
Rationale: Rationale: The correct answer is A) Protect cornea with lubricant and eye shields. In Guillain-Barre syndrome, paralysis of all extremities can lead to impaired blinking reflex, which puts the client at risk for corneal damage due to inadequate eye protection. By protecting the cornea with lubricant and eye shields, the nurse can prevent corneal abrasions and exposure keratitis, which can occur due to the inability to blink. Option B) Administer artificial tears every hour is incorrect because simply administering artificial tears does not address the need for protecting the cornea from damage. Option C) Encouraging the client to blink every 10 minutes is incorrect as the client's paralysis may prevent them from being able to blink voluntarily. Option D) Keeping the client's eyes closed with adhesive tape is incorrect because this can lead to further complications such as corneal abrasions and discomfort. Educational context: Understanding the importance of eye care in patients with Guillain-Barre syndrome is crucial for nursing care. By protecting the cornea with lubricant and eye shields, nurses can prevent serious eye complications and promote the overall well-being of the patient. This scenario highlights the need for vigilant assessment and proactive interventions to prevent potential complications in critically ill patients.
Question 4 of 5
A male client in skeletal traction tells the nurse that he is frustrated because he needs help repositioning himself in bed. Which intervention should the nurse implement?
Correct Answer: A
Rationale: In this scenario, the correct intervention is option A, which is to provide an overhead trapeze to the bed for the client to use. This is the most appropriate intervention because it empowers the client to reposition himself independently, promoting autonomy and preserving his dignity. Option B, assisting the client with repositioning every hour, may not be feasible due to staffing constraints and may not address the client's frustration with needing constant assistance. Option C, encouraging the use of a bedpan, does not address the client's need for repositioning and mobility, which are important for preventing complications associated with immobility. Option D, offering additional pain medication, does not address the client's need for repositioning and may not be the most appropriate solution for his frustration with his limited mobility. Educationally, it is important for nurses to promote independence and autonomy in patients whenever possible, especially in situations where the client's frustration with limited mobility needs to be addressed. Providing assistive devices like an overhead trapeze not only helps the client physically but also psychologically by giving him a sense of control over his own care.
Question 5 of 5
A client tells the nurse that her biopsy results indicate that the cancer cells are well-differentiated. How should the nurse respond?
Correct Answer: A
Rationale: Rationale: The correct answer is A) Ask the client if the healthcare provider has given her any information about the classification of her cancer. Explanation: 1. Option A is correct because it demonstrates therapeutic communication by encouraging the client to seek clarification from her healthcare provider. This empowers the client to better understand her condition and treatment options. 2. Option B is incorrect because stating that well-differentiated cancer cells usually have a poor prognosis is inaccurate. Well-differentiated cells are more similar to normal cells and may indicate a less aggressive cancer type. 3. Option C is incorrect as it provides false reassurance. All cancer diagnoses should be taken seriously, and it is essential to provide accurate information and support to the client. 4. Option D is incorrect because encouraging the client to seek a second opinion without clarifying the information provided by the healthcare provider may lead to confusion and delay in necessary treatment. Educational Context: Understanding cancer cell differentiation is crucial in determining the aggressiveness and prognosis of cancer. Well-differentiated cells resemble normal cells and may indicate a less aggressive cancer type compared to poorly differentiated cells. As a nurse, it is important to facilitate open communication, provide accurate information, and support clients in seeking clarification from their healthcare providers to make informed decisions about their care.