ATI RN
Maternity and Pediatric Nursing 4th Edition Test Bank Questions
Question 1 of 5
When caring for a patient with AIDS, which of the following nursing actions would be the most appropriate for infection control?
Correct Answer: C
Rationale: The most appropriate nursing action for infection control when caring for a patient with AIDS is to wear gloves for blood/body fluid contact. HIV, the virus that causes AIDS, is primarily spread through exposure to infected blood or body fluids. Therefore, wearing gloves when there is a potential for blood or body fluid contact is crucial in preventing the transmission of the virus. Wearing gloves at all times may not be necessary if there is no direct contact with blood or body fluids, and wearing a gown and mask at all times may not be indicated unless there is a specific need based on the situation. Wearing a mask during patient contact times may also not be necessary unless there is a risk of exposure to respiratory secretions.
Question 2 of 5
The nurse is observing a client receiving antiplatelet therapy for adverse reactions. Antiplatelet drugs most commonly produce which hypersensitivity reaction?
Correct Answer: C
Rationale: Antiplatelet drugs most commonly produce bronchospasm as a hypersensitivity reaction. This adverse reaction occurs due to the release of bronchoconstrictive mediators, leading to narrowing of the airways and potentially causing respiratory distress. It is important for nurses to closely monitor clients receiving antiplatelet therapy for signs of bronchospasm, such as wheezing, shortness of breath, and chest tightness, and to intervene promptly to prevent further complications. Difficulty hearing, confusion, and agranulocytosis are not typically associated with antiplatelet therapy.
Question 3 of 5
The nurse is preparing a parent of a newborn for home phototherapy. Which statement made by the parent would indicate a need for further teaching?
Correct Answer: D
Rationale: The correct statement should be that the patches need to remain on the baby's eyes at all times during phototherapy. Removing the eye patches can potentially allow harmful light exposure to the eyes, which can lead to complications such as eye damage. It is essential for the parent to understand the importance of keeping the eye patches on to protect the baby's eyes during phototherapy. Therefore, further teaching is needed to emphasize the importance of leaving the eye patches on at all times, even during feedings and caregiving activities.
Question 4 of 5
A nurse finds Mr. Gabatan under the wreckage of the car. He is conscious, breathing satisfactorily, and lying on the back complaining of pain in the back and an inability to move his legs. The nurse should first:
Correct Answer: C
Rationale: The correct initial action in this scenario would be to roll Mr. Gabatan on his abdomen, placing a pad under his head, and covering him with any material available. This position is known as the recovery position, and it is important for individuals who have suspected spinal injuries. By rolling Mr. Gabatan onto his abdomen, it helps protect his spine and prevent further injury. Placing a pad under his head provides some support, and covering him with material helps to keep him warm and comfortable while waiting for additional help to arrive. It is crucial to avoid movement, especially if there is a suspected spinal injury, as moving the individual incorrectly can worsen the injury and lead to permanent damage.
Question 5 of 5
The nurse is assessing a child after a cardiac catheterization. Which complication should the nurse be assessing for?
Correct Answer: A
Rationale: After a cardiac catheterization, the nurse should be assessing for the development of cardiac arrhythmias, as this is a potential complication associated with the procedure. Cardiac arrhythmias can occur due to irritation of the heart during the catheterization, changes in electrolyte levels, or other factors related to the procedure. Monitoring the child's cardiac rhythm closely allows for early detection and management of arrhythmias to prevent serious complications. While other complications such as hypostatic pneumonia, heart failure, and rapidly increasing blood pressure can also occur, cardiac arrhythmia is the most important complication to assess for immediately post-cardiac catheterization.