ATI RN
RN Nursing Care of Children 2019 With NGN
1. What is an appropriate nursing intervention for a child with minimal change nephrotic syndrome (MCNS) who has scrotal edema?
- A. Place an ice pack on the scrotal area.
- B. Place the child in an upright sitting position.
- C. Elevate the scrotum with a rolled washcloth.
- D. Place a warm moist pack to the scrotal area.
Correct answer: C
Rationale: Elevating the scrotum with a rolled washcloth helps reduce edema by promoting fluid drainage. Ice packs are not recommended due to the risk of frostbite, and warm moist packs are not typically used for this purpose. An upright position does not specifically address the edema.
2. A client scheduled for hysterosalpingography needs health teaching before the procedure. The nurse is correct in telling the patient that:
- A. She needs to void prior to the procedure
- B. A full bladder is needed prior to the procedure
- C. Painful sensation is felt as the needle is inserted
- D. Flushing sensation is felt as the dye in injected
Correct answer: A
Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.
3. A client does not understand why vision loss due to glaucoma is irreversible. What is the nurse’s best explanation?
- A. Once retinal detachment occurs, it does not return to its normal state
- B. Once the tissue has necrosed from high-pressure, it does not regenerate
- C. Glaucoma always leads to permanent blindness
- D. Once bacterial infection has caused damage, the tissue does not regenerate
Correct answer: Once the tissue has necrosed from high-pressure, it does not regenerate
Rationale: The correct explanation for irreversible vision loss in glaucoma is that once the tissue has necrosed from high pressure, it does not regenerate. This necrosis occurs due to the damage caused by increased intraocular pressure, which leads to irreversible damage to the optic nerve and retinal tissue. Choices A, C, and D are incorrect because they do not directly address the specific mechanism of irreversible vision loss in glaucoma, which is necrosis due to high pressure.
4. A client reports that the medication the nurse is administering appears different than what they take at home. Which of the following responses should the nurse take?
- A. Did the doctor discuss with you that there was a change in this medication?
- B. I recommend that you take this medication as prescribed
- C. Do you know why this medication is being prescribed to you?
- D. I will call the pharmacist now to check on this medication
Correct answer: I will call the pharmacist now to check on this medication
Rationale: When a client reports that the medication appears different than what they take at home, it is crucial for the nurse to ensure the safety and accuracy of the medication being administered. The most appropriate action for the nurse to take in this situation is to call the pharmacist to verify the medication, dosage, and any potential changes. This proactive step helps prevent medication errors and ensures the client's safety and well-being.
5. The client is complaining of painful swallowing secondary to mouth ulcers. Which statement by the client indicates appropriate management?
- A. “I will brush my teeth with a soft-bristle toothbrush.”
- B. “I will rinse my mouth with Listerine mouthwash.”
- C. “I will swish my antifungal solution and then swallow.”
- D. “I will avoid spicy foods, tobacco, and alcohol.”
Correct answer: D
Rationale: The correct answer is D. Avoiding irritants like spicy foods, tobacco, and alcohol is crucial in managing mouth ulcers as they can further irritate the ulcers and delay healing. Choices A, B, and C could potentially worsen the condition. Brushing with a soft-bristle toothbrush may cause discomfort, rinsing with Listerine mouthwash can be too harsh on the ulcers, and swallowing antifungal solution is not recommended unless specified by a healthcare provider.
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