ATI RN
RN Nursing Care of Children Online Practice 2019 A
1. What is a clinical manifestation of acetaminophen poisoning?
- A. Hyperpyrexia
- B. Hepatic involvement
- C. Severe burning pain in stomach
- D. Drooling and inability to clear secretions
Correct answer: B
Rationale: Acetaminophen poisoning primarily affects the liver, leading to hepatic involvement, which may present as jaundice, liver failure, or elevated liver enzymes. Hyperpyrexia, severe pain, and drooling are more associated with other types of poisoning.
2. A client is taking Desmopressin for Diabetes Insipidus. For which of the following adverse effects should the nurse monitor?
- A. Hypovolemia
- B. Hypercalcemia
- C. Agitation
- D. Headache
Correct answer: D
Rationale: Headache is an adverse effect that the nurse should monitor for in a client taking Desmopressin for Diabetes Insipidus. It can be an early sign of water intoxication, which is a potential complication of desmopressin therapy due to excessive water retention in the body.
3. Which of the following expected outcomes would be most appropriate for a client with peptic ulcer disease? The client will:
- A. verbalize absence of epigastric pain.
- B. accept the need to inject himself with vitamin B12 for the rest of his life.
- C. understand the need to increase his exercise activity.
- D. eliminate stress from his life.
Correct answer: A
Rationale: A realistic goal for this client would be to gain relief from epigastric pain. There is no need for vitamin B12 injections because this client has not had any gastric surgery that would lead to vitamin B12 deficiency. Exercise should be modified, not increased, because it can stimulate further production of gastric acid. It is not possible to eliminate stress from a client's life. Instead, the client should be assisted to develop effective coping and problem-solving strategies as necessary.
4. A nurse is assessing a client who is 30 minutes postoperative following an arterial thrombectomy. What should the nurse report?
- A. Chest pain.
- B. Muscle spasms.
- C. Cool, moist skin.
- D. Incisional pain.
Correct answer: A
Rationale: In this scenario, postoperative chest pain is a critical finding that must be reported promptly. Chest pain after an arterial thrombectomy could indicate serious complications such as myocardial infarction or pulmonary embolism. Muscle spasms and cool, moist skin are not the priority assessments in this situation. Incisional pain is common after surgery and is not typically a cause for immediate concern unless it is severe and accompanied by other symptoms.
5. A client has been given instructions about ferrous sulfate. Which statement made by the client would indicate the client needs further education?
- A. "I will take this medication with a full glass of milk."
- B. "I will take the morning dose 1 hour before breakfast."
- C. "I will need to avoid taking this medication with coffee."
- D. "I will take antacids if needed, 2 hours after I take ferrous sulfate."
Correct answer: A
Rationale: The correct answer is A. Ferrous sulfate should not be taken with milk as it can impair iron absorption. Choice B is correct as taking the morning dose 1 hour before breakfast is appropriate. Choice C is correct as coffee can interfere with iron absorption. Choice D is correct as antacids should be taken 2 hours after ferrous sulfate to avoid interference with its absorption.
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