the nurse is monitoring a patient receiving a heparin infusion for the treatment of pulmonary embolism which assessment finding most likely related to
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Nursing Elites

ATI RN

ATI Pediatric Proctored Exam 2023

1. The patient is receiving a heparin infusion for the treatment of pulmonary embolism. Which assessment finding is most likely related to an adverse effect of heparin?

Correct answer: C

Rationale: The primary and most serious adverse effect of heparin is bleeding. However, discolored urine can indicate bleeding into the urinary tract, which is a potential adverse effect of heparin therapy. While changes in heart rate (HR) and blood pressure (BP) can occur due to various reasons, discolored urine specifically points towards a potential adverse effect related to heparin therapy.

2. The 6-year-old child scheduled for an orchiopexy shyly asks the nurse, 'What are they going to do to me 'down there'? What is the nurse's best response?

Correct answer: C

Rationale: The nurse should encourage the child to express his thoughts and feelings about the upcoming surgery. This approach helps the child feel heard and understood while providing an opportunity to address any misconceptions or fears. By asking the child what he thinks the doctor will do, the nurse engages the child in a conversation that can help alleviate anxiety and build trust. School-age children often have fears related to bodily harm, and open communication can help alleviate such concerns. Choices A and D do not encourage open communication or address the child's concerns directly. Choice B provides too much detail that may overwhelm the child and is not age-appropriate for a 6-year-old.

3. While auscultating the lungs of an adolescent with asthma, what should the nurse identify the sound as?

Correct answer: C

Rationale: The nurse should identify the sound heard during auscultation as tachypnea, which is characterized by a rapid, regular breathing pattern. In the case of an adolescent with asthma, tachypnea can be indicative of increased work of breathing due to airway constriction and inflammation. Biots respiration (choice A) is characterized by an irregular pattern of breathing with periods of apnea. Chaney-Stokes respiration (choice B) is a pattern of breathing characterized by alternating periods of deep, rapid breathing followed by periods of apnea. Bradypnea (choice D) refers to an abnormally slow breathing rate, which is not typically associated with asthma exacerbation.

4. The therapist engages a teen in a game of cards to improve his hand skills for schoolwork. Which statement best reflects this session?

Correct answer: C

Rationale: The correct answer is 'Play as a tool.' In this session, the therapist is using play as a tool to integrate therapeutic goals into a playful activity, which helps engage the teen and improve specific skills, in this case, hand skills for schoolwork.

5. A parent of an infant with diaper dermatitis is being taught by a nurse. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The nurse should instruct the parent to expose the infant's skin to air as it helps in promoting the healing process of diaper dermatitis by allowing the skin to breathe and reducing moisture, which can worsen the condition.

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