the nurse in the pediatric clinic performs a physical assessment of a 13 year old boy which of the following findings by the nurse requires an immedia
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 5

1. The nurse in the pediatric clinic performs a physical assessment of a 13-year-old boy. Which of the following findings by the nurse requires an immediate intervention?

Correct answer: D

Rationale: A swollen and thickened spermatic cord could indicate testicular torsion, which is a surgical emergency.

2. What is the FIRST step in providing health care for a patient?

Correct answer: B

Rationale: The correct first step in providing health care for a patient is to determine the needs of the patient. Understanding the patient's requirements, concerns, and medical history is crucial before proceeding with any further steps. Option A, 'Obtain and interpret vital signs,' may be necessary but typically follows assessing the patient's needs. Option C, 'Develop a plan of care,' comes after identifying the patient's needs. Option D, 'Obtain lab work and x-rays,' is usually done based on the patient's needs and the developed plan of care, making it a later step in the process.

3. Which discharge instruction should the nurse teach the client diagnosed with varicose veins who has received sclerotherapy?

Correct answer: A

Rationale: The correct answer is to instruct the client to walk 15 to 20 minutes three times a day. Walking is beneficial as it helps improve circulation and reduces the risk of complications following sclerotherapy. Choice B is incorrect because keeping the legs in the dependent position when sitting can lead to increased venous pressure, worsening varicose veins. Choice C is incorrect as compression bandages should typically be worn continuously, especially during the initial healing phase. Choice D is incorrect as Berger-Allen exercises are not commonly associated with post-sclerotherapy care.

4. The client diagnosed with thalassemia, a hereditary anemia, is to receive a transfusion of packed RBCs. The cross-match reveals the presence of antibodies that cannot be cross-matched. Which precaution should the nurse implement when initiating the transfusion?

Correct answer: A

Rationale: Starting the transfusion slowly at 10-15 mL per hour for 15-30 minutes is essential when the cross-match reveals the presence of antibodies that cannot be cross-matched. This precaution allows the nurse to monitor for any adverse reactions due to the antibodies. Re-crossmatching the blood until the antibodies are identified (choice B) may delay the transfusion process and put the client at risk. Having the client sign a permit to receive uncrossmatched blood (choice C) is not a standard practice and does not address the immediate need for precautions during transfusion. Having the unlicensed nursing assistant stay with the client (choice D) is unrelated to the safe initiation of the transfusion and is not a precaution specific to managing antibodies in blood products.

5. The client is recovering from a percutaneous renal biopsy. Which data indicate that the client is complying with client teaching?

Correct answer: A

Rationale: The correct answer is A. Lying flat in the supine position for 12 hours after a renal biopsy helps prevent bleeding, which is crucial for the client's recovery. This position aids in applying pressure to the biopsy site, reducing the risk of bleeding and ensuring optimal healing. Choices B, C, and D do not directly relate to compliance with client teaching after a renal biopsy. Continuing oral fluids restriction, changing the dressing, or activating a patient-controlled analgesia pump are not specific instructions aimed at promoting recovery and preventing complications post renal biopsy.

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