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. The nurse instructs a client 5 days after a lumbar laminectomy with spinal fusion about how to move from a supine position to standing at the left side of the bed with a walker. Which of the following directions by the nurse is BEST?

Correct answer: C

Rationale: Choice C is the best direction provided by the nurse. This method involves reaching over to the left side rail with the right hand, pulling the body onto its side, bending the upper leg so the foot is on the bed, and pushing down to elevate the trunk. This approach helps maintain spinal alignment while moving from a lying to a standing position, reducing strain on the back. Choices A, B, and D involve movements that are not suitable for a client recovering from a lumbar laminectomy with spinal fusion and could potentially cause harm or discomfort.

3. The nurse is planning to provide education about foods containing thiamine to a group of clients. Which food high in thiamine should the nurse include?

Correct answer: B

Rationale: The correct answer is B: Pork. Pork is high in thiamine, which is important for preventing thiamine deficiency. Thiamine, also known as vitamin B1, is essential for the proper functioning of the nervous system and metabolism. While fish, beef, and eggs are nutritious foods, they are not as high in thiamine as pork. Fish is more commonly known for its omega-3 fatty acids, beef for its iron content, and eggs for being a good source of protein and other nutrients.

4. What is the best position to measure the leg circumference of a client with bipedal edema?

Correct answer: A

Rationale: When measuring the leg circumference of a client with bipedal edema, the best position to ensure accurate and consistent measurements is the dorsal recumbent position. This position allows the legs to be comfortably positioned, with the individual lying on their back and legs extended. This facilitates accurate measurement of the circumference without the influence of gravity. Sitting and standing positions may not provide optimal conditions for accurate leg circumference measurements as they may not allow the legs to be fully extended. The supine position, although similar to dorsal recumbent, may not provide the same level of comfort and accuracy in leg circumference measurement for a client with bipedal edema.

5. 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 the correct precaution to implement when the cross-match reveals the presence of antibodies that cannot be cross-matched. This allows the nurse to monitor for any adverse reactions due to the presence of antibodies. Re-crossmatching the blood until the antibodies are identified is not practical and may delay the transfusion, potentially compromising the patient's condition. Having the client sign a permit to receive uncrossmatched blood is not the best course of action as the focus should be on ensuring a safe transfusion. Having an unlicensed nursing assistant stay with the client does not address the specific precaution needed to manage a transfusion in the presence of antibodies.

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