ATI LPN
Questions on Immune System Questions
Question 1 of 5
Which nursing diagnosis is highest-priority for a 3-year-old child undergoing chemotherapy and experiencing nausea and vomiting?
Correct Answer: A
Rationale: The correct answer is A: Deficient Fluid Volume. For a child undergoing chemotherapy with nausea and vomiting, dehydration from fluid loss is a critical concern. Maintaining fluid balance is essential for the child's health and well-being. Options B, C, and D are not as high-priority because addressing fluid volume deficiency takes precedence over addressing nutrition, comfort, or body image issues in this situation.
Question 2 of 5
A nurse caring for a client with disseminated intravascular coagulation (DIC) is reviewing the client’s diagnostic tests. Which test result is common in DIC?
Correct Answer: C
Rationale: The correct answer is C: Decreased fibrinogen level. In DIC, there is widespread activation of clotting factors leading to consumption of fibrinogen, causing a decrease in its levels. This results in an increased risk of bleeding. A: Decreased prothrombin time is not common in DIC because the increased clotting factor consumption leads to a prolonged prothrombin time. B: Increased platelet count is not common in DIC, as platelets are also consumed in the excessive clotting process. D: Decreased partial thromboplastin time is not common in DIC as it may be prolonged due to consumption of clotting factors.
Question 3 of 5
A 24-hour urine collection for vanillylmandelic acid (VMA) has been ordered on a child suspected of having neuroblastoma. When is the most appropriate time for the nurse to begin the collection?
Correct Answer: B
Rationale: The correct answer is B: After the next time the child voids. This is because the first void is discarded to ensure that the urine collection is accurate. By starting the collection after the next void, we can capture a full 24-hour sample. Choice A is incorrect because starting at 0700 does not account for the child's first void. Choice C is incorrect because starting at bedtime also does not allow for the exclusion of the first void. Choice D is incorrect as starting when the order is noted does not ensure the accuracy of the collection.
Question 4 of 5
When caring for a child with leukemia, which of the following goals should be considered primary?
Correct Answer: C
Rationale: The correct answer is C: Preventing infection. In children with leukemia, the primary goal is to prevent infection due to their compromised immune system. Infection can be life-threatening for these patients. Providing a safe environment, proper hand hygiene, and monitoring for signs of infection are crucial. Meeting developmental needs (A) and promoting adequate nutrition (B) are important but secondary to preventing infection. Promoting diversionary activity (D) is beneficial for psychosocial well-being but not as critical as preventing infection in a child with leukemia.
Question 5 of 5
A child with nephrotic syndrome is severely edematous. The primary health-care provider has placed the child on bed rest. An important nursing intervention for this child should be to
Correct Answer: A
Rationale: The correct answer is A: Reposition the child every two hours. In nephrotic syndrome, edema is common due to protein loss. Bed rest helps reduce fluid retention. Repositioning every two hours prevents pressure ulcers. Monitoring blood pressure frequently (B) is not necessary unless indicated. Encouraging fluids (C) can exacerbate edema. Limiting visitors (D) is not directly related to managing edema.