ATI LPN
Immune System Questions Questions
Question 1 of 5
Which of the following would be an appropriate nursing diagnosis for a child who is receiving chemotherapy?
Correct Answer: D
Rationale: The correct answer is D: Impaired oral mucous membrane. This is an appropriate nursing diagnosis for a child receiving chemotherapy because chemotherapy often causes mucositis, leading to pain, difficulty eating, and an increased risk of infection in the oral cavity. Nurses need to assess and monitor oral mucous membranes closely in these patients. Incorrect choices: A: Ineffective breathing pattern - Not directly related to chemotherapy in this scenario. B: Constipation - Not typically a common issue specifically related to chemotherapy. C: Impaired skin integrity - Not directly related to the side effects of chemotherapy on oral mucous membranes.
Question 2 of 5
The client in end-stage of renal failure had undergone kidney transplant. Which of the following assessment findings indicate kidney transplant rejection?
Correct Answer: C
Rationale: The correct answer is C. Decreased urinary output and sudden weight gain indicate kidney transplant rejection. Decreased urinary output suggests decreased kidney function, while sudden weight gain can be due to fluid retention caused by rejection. Increased urinary output and normal BUN indicate proper kidney function. High HCT and Hgb levels indicate good oxygen-carrying capacity, ruling out rejection. Decreased urinary output and weight loss are not typical signs of rejection.
Question 3 of 5
A child with severe gastroenteritis is admitted to a semiprivate room on the pediatric unit. The charge nurse should place this client with which roommate?
Correct Answer: C
Rationale: The correct answer is C. Placing the child with another child with gastroenteritis is the best option to prevent transmission of the infection to other vulnerable patients. Choosing option A would risk exposing the child with meningitis to gastroenteritis. Option B involves a child with neutropenia who is immunocompromised and at high risk for infection. Option D may not be ideal as the child recovering from an appendectomy may have a weakened immune system and could be at risk for acquiring gastroenteritis. Placing the child with another case of gastroenteritis minimizes the risk of spreading the infection and ensures appropriate care and isolation measures are in place.
Question 4 of 5
The nurse is teaching the parents of a 4-month-old infant about good feeding habits. The nurse emphasizes the importance of holding the baby during feeding and not letting the infant go to sleep with the bottle. Which disorder is associated with propped feedings and going to sleep with the bottle?
Correct Answer: A
Rationale: The correct answer is A: Otitis media. Propped feedings and letting the baby sleep with a bottle can lead to increased risk of otitis media, an ear infection. When a baby is propped up during feeding, there is a greater chance of liquid entering the middle ear through the Eustachian tube, leading to infection. All other choices (B: Aspiration, C: Malocclusion problems, D: Sleeping disorders) are not directly associated with propped feedings and bottle sleeping in infants.
Question 5 of 5
A mother asks when toilet training is most appropriately initiated. What would be the nurse’s best response?
Correct Answer: B
Rationale: The correct answer is B because toilet training should be initiated when the child shows signs of physical and psychological readiness, such as staying dry for longer periods, showing interest in using the toilet, and being able to communicate their needs. This approach ensures a more successful and less stressful toilet training experience for both the child and the parent. Choice A is incorrect because starting toilet training based solely on age may not align with the child's individual readiness. Choice C is incorrect as walking ability does not necessarily indicate readiness for toilet training. Choice D is incorrect because the ability to sit on the potty for a specific time does not guarantee readiness for toilet training.