ATI RN
Burns Pediatric Primary Care Test Bank Questions
Question 1 of 5
Why may an ice collar be ordered for a client who is undergoing drainage of a peritonsillar abscess?
Correct Answer: B
Rationale: An ice collar may be ordered for a client undergoing drainage of a peritonsillar abscess to prevent respiratory obstruction. Peritonsillar abscess is a collection of pus behind the tonsils, and the inflammation and swelling from the abscess can lead to difficulty in breathing or swallowing. Applying an ice collar can help reduce the swelling and prevent the abscess from compressing the airway, thus reducing the risk of respiratory obstruction. It can provide comfort to the client and support the drainage process by minimizing the swelling and promoting better drainage of the abscess.
Question 2 of 5
A patient, who had a hysterectomy 2 days ago, reports tenderness in her left calf. The nursing assessment reveals the following: left calf 17.5", right calf 14", left thigh 32", right thigh 28", and a shiny, warm, and reddened left leg. Which of the following interventions should be given priority in the patient's plan of care? i. Maintain bedrest ii. Encourage ambulation TID iii. Apply bilateral antiembolism v. Apply right antiembolism stockings stockings vi. Apply warm moist heat as ordered iv. Encourage bilateral leg exercises
Correct Answer: A
Rationale: The patient's symptoms and assessment findings suggest the presence of deep vein thrombosis (DVT), which is a potential complication following surgery such as a hysterectomy. The priority interventions in this case should focus on preventing the progression of DVT and reducing the risk of pulmonary embolism.
Question 3 of 5
Which of the following types of cells is the immune system's shutoff mechanism?
Correct Answer: B
Rationale: Suppressor T cells, also known as regulatory T cells, play a critical role in regulating the immune response by acting as the immune system's shutoff mechanism. These cells help maintain immune tolerance and prevent overactivation of the immune system, thereby preventing autoimmune reactions and excessive inflammation. Suppressor T cells exert their immunosuppressive effects by inhibiting the function of other immune cells, such as effector T cells and B cells, and helping to control the overall balance of the immune system.
Question 4 of 5
A male client is suspected of an immune system disorder. Which of the ff important factors will the nurse document while assessing the client?
Correct Answer: D
Rationale: Assessing the client's ability to produce antibodies is a crucial factor in determining immune system function. Antibodies are proteins produced by the immune system to help fight off infections and other harmful substances. In a male client suspected of an immune system disorder, understanding his ability to produce antibodies can provide valuable insights into the functionality of his immune system. This assessment can help healthcare providers identify potential deficiencies or abnormalities in the immune response, leading to appropriate diagnosis and treatment strategies.
Question 5 of 5
The nurse is taking vital signs of a pregnant woman during her first prenatal visit. The patient asks the nurse if she has to have an HIV test. Which of the following is the nurse's best response?
Correct Answer: D
Rationale: The nurse's best response is D, "After voluntary pretest counseling, you decide whether HIV testing should be done." It is important for the pregnant woman to make an informed decision about HIV testing after receiving pretest counseling. The decision should be based on her individual risk factors, concerns, and preferences. The nurse should provide information about the importance of HIV testing during pregnancy, the benefits of knowing one's HIV status, and the available treatment options if the test is positive. Ultimately, the decision should be made by the pregnant woman after considering all the information provided.