ATI LPN
Immune System Practice Questions Questions
Question 1 of 5
What is the best way for the nurse to detect fluid retention in a child with nephrotic syndrome who has not yet been toilet-trained?
Correct Answer: A
Rationale: The correct answer is A: Weigh the child daily. Daily weight monitoring is essential in detecting fluid retention in a child with nephrotic syndrome as it is a sensitive indicator of changes in fluid status. Fluid retention can lead to weight gain, indicating a worsening condition. Checking urine for blood (B) is more relevant for detecting renal issues, not fluid retention. Measuring abdominal girth weekly (C) may not be as sensitive or specific as daily weight monitoring. Counting the number of wet diapers (D) is more relevant for assessing hydration status rather than fluid retention. In summary, daily weight monitoring is the most accurate and sensitive method for detecting fluid retention in this scenario.
Question 2 of 5
The nurse is caring for a child with disseminated intravascular coagulation (DIC). Which nursing intervention is a priority for this child?
Correct Answer: B
Rationale: The correct answer is B: Maintenance of skin integrity. For a child with DIC, skin integrity is a priority due to the risk of bleeding and clotting. Skin breakdown can lead to infection and further complications. Monitoring fluid restriction (choice C) may be important, but skin integrity takes precedence. Frequent ambulation (choice A) may be beneficial but not as crucial as maintaining skin integrity. Preparation for x-ray procedures (choice D) is not a priority compared to preventing skin breakdown in a child with DIC.
Question 3 of 5
A client with disseminated intravascular coagulation (DIC) has a nursing diagnosis of Impaired Gas Exchange. Which action is inappropriate when providing care based on this nursing diagnosis?
Correct Answer: A
Rationale: Correct answer: A. Placing the client in a low-Fowler position is inappropriate because it can worsen gas exchange in a client with DIC. Rationale: 1. In DIC, impaired gas exchange is often due to microthrombi formation in the lungs, leading to ventilation-perfusion mismatch. 2. Placing the client in a low-Fowler position can further compromise ventilation by decreasing lung expansion and worsening perfusion. 3. Monitoring oxygen saturation continuously (B) is essential in assessing gas exchange status. 4. Maintaining bed rest (C) helps reduce oxygen demand and prevent complications from movement. 5. Encouraging deep breathing and coughing (D) can help maintain lung expansion and prevent atelectasis. In summary, placing the client in a low-Fowler position is inappropriate as it can worsen gas exchange, while monitoring oxygen saturation, maintaining bed rest, and promoting deep breathing and coughing are appropriate interventions for a client with DIC and impaired gas exchange.
Question 4 of 5
The child is admitted to the hospital after being diagnosed with retinoblastoma. Which assessment finding does the nurse anticipate for this child?
Correct Answer: C
Rationale: The correct answer is C: A white pupil. Retinoblastoma is a malignant tumor of the retina that can present as a white pupil in flash photography, known as leukocoria. This is due to the tumor blocking the normal red reflex from the retina. A red reflex (choice A) is a normal finding and not expected in retinoblastoma. Yellow sclera (choice B) and blue-tinged sclera (choice D) are not typically associated with retinoblastoma.
Question 5 of 5
A nurse enters the room of a teenager after the physician has obtained informed consent for a voiding cystourethrogram. The teenager asks the nurse to explain the procedure again. The nurse tells the client that the client is asked to void after:
Correct Answer: C
Rationale: The correct answer is C: Injection of contrast dye into the bladder via a catheter. In a voiding cystourethrogram, contrast dye is indeed injected into the bladder via a catheter to visualize the urinary tract during voiding. This allows for the assessment of bladder and urethra function. Choices A and D are incorrect because radioisotopes are not typically used in this procedure. Choice B is incorrect as contrast dye is not injected into the bloodstream but rather directly into the bladder. Therefore, the correct answer is C as it accurately describes the procedure for a voiding cystourethrogram.