ATI PN NURSING CARE OF CHILDREN NGN 2020 EXA
m m m m m m m m
M & PRACTICE EXAMS 250 QUESTIONS AND CORREC
m m m m m m m
T DETAILED ANSWERS (VERIFIED
m m m
ANSWERS) WITH RATIONALES |ALREADY GRADED A
m m m m m
+
Amnursemismcaringmformamclientmwhomismtakingmlithiummandmreportsmpersistentmnauseamandmvomitingmform2
m days.m Whichmofm them followingm laboratorym valuesmshouldm them nursem reportm tom them provider?m -
m ANSWER-D. m Sodiumm 132m mEq/L
Rationale:
The mnurse mshouldmidentifymthatmamsodiummlevelmofm132mmEq/Lmismnotmwithinmthemexpectedmreference mra
nge mofm136mtom145mmEq/L.mThismfindingmindicatesmhyponatremia,mwhichmcanmleadmtomlithiummaccumulati
onmandmplacesmthemclientmatmriskmformlithiummtoxicity.mThemnursemshouldmreportmthismfindingmtomthemprov
ider.
Amnurse mismcaringmformamclientmwhomhasmcancermandmhasmamWBCmcountmofm4,000/mm3.mWhichmofmthe mfoll
owingmactionsmshouldmthe mnurse mtake?m-mANSWER-
A.mCleanse mthe mclient'smtoothbrushmwithmhydrogenmperoxide.
Rationale:
AmWBCmcountmofm4,000/mm3mismconsideredmlowmandmismknownmasmleukopenia.mAmlowmWBCmcountmcan
m be m causedm by mcancerm orm cancermtreatment. mThemnurse mshouldminstructmthemclientmtomcleanse mtheirmto
othbrushmwithmhydrogenmperoxide.mPeoplemwithmleukemiamormleukopeniamshouldmavoidmusingmdisposa
ble mrazors,mwhichmcanmcausemcutsmandmbleedingmthatmcanmleadmtominfections.mInstead,mtheymrecomme
ndmusingmanmelectricmrazormtomreduce mthemriskmofminjury.mEncouragingmthemclientmtomeatmunpasteurized
m dairy m products m is
notmrecommendedmasmtheymcanmcontainmharmfulmbacteriamthatmcanmcauseminfections.mDecreasingmthe mcli
ent'smproteinmintakemismnotmrecommendedmasmproteinmismimportantmformwoundmhealingmandmimmune mfu
nction
TEST
Amnurse mentersmamclient'smroommandmseesmsmokemcomingmfrommthembathroom.mWhichmofmthemfollowin
gmactionsmshouldmthe mnurse mtake mfirst?
a) Activate mthe mfire malarmmsystem.
b) Use mamfire mextinguishermatmthemsource mofmt
he msmoke.
c) Assistmthe mclientmtomamnearbymcommonmarea.
d) Close mthe mdoorsmtomthe mroommandmtomthe
,bathroom.m-mANSWER-C.mAssistmthe mclientmtomamnearbymcommonmarea.
Rationale:
use mRescu
e mAlarmmC
ontainmExt
inguish
TEST
Amnurse mismcontributingmtomthemplanmofmcare mformamclientmwhomreportsmdifficultymeatingmduemtomchronic
m arthritis. m Whichm of m the m followingm interventions m should m the m nurse m include m inm the m plan?
a) Applymfoammhandlesmtomthe mclient'smeatingmutensils.
b) Obtainmamreferralmformphysicalmtherapy.
c) Have manmassistive mpersonnelmfeedmthe mclient.
d) Askmthe mprovidermformamprescriptionmformampureedmdiet.m-mANSWER-
A.mApplymfoammhandlesmtomthe mclient'smeatingmutensils.
Rationale:
Tomhelpmamclientmwithmchronicmarthritismwhomexperiencesmdifficultymeating,mapplyingmfoammhandlesmtomth
e meatingmutensilsmcanmprovidemamlarger,mmore mcomfortablemgripmandmreducemstrainmonmthemjoints.mAskin
gmformampureemdietmmaymnotmbemnecessarymunlessmswallowingmdifficultiesmarempresent.mHavingmanmassisti
ve mpersonnelmfeedmthemclientmmaymnotmpromotemindependence.mWhile mobtainingmamreferralmformphysical
m therapy m maym bembeneficialm formoverallm mobility, m itmdoesmnotm directly m address mthem client'sm difficulty mwit
hmeating.
Amnurse mismprovidingmdirectionsmtomanmassistive mpersonnelmaboutmmovingmamclientmupminmbed.
a. "Place mampillowmundermthe mclient'smheadmpriormtomrepositioning."
b. "Keepmyourmfeetmclosemtogethermwhile mmovingmthe mclie
nt"mcm"Face minmthemdirectionmof mthe mclient'smmovement"
d.m"Move mthe mclient'smarmsmtomhismsidesmpriormtomrepositioning."m-mANSWER-
C.m"Face minmthe mdirectionmofmthe mcliet'smmovement."
Rational:
Whenmmovingmamclientmupminmbed,mitmismimportantmformthemnursemtomfaceminmthe mdirectionmof mthemclient's
m movementm tom maintain m properm body m mechanics m andm ensure m safe m transfer.
,1) Adjustm the m headm of m the m bedm tom am flatm position.
2) Remove m allm pillowsm fromm underm the m client.
3) Positionm the m UAPm onm the m side m opposite m the m nurse.
4) Place m am friction-reducingm sheetm underm the m client.
5) Askm the m clientm tom bendm the m legsm andm place m the m chinm onm the m chest.
6) Graspm the m sheetm andm move m the m clientm onm the m countm of m three.
Amnurse mismobtainingmammedicationmhistorymfrommamclientmwhomismtomstartmtakingmnitroglycerinmformchest
m discomfortm withmactivity. mWhichmofmthem followingmmedications mshouldmthe mnursem instructmthemclientmtom
avoidmtakingmwithinm24mhrsmofmusingmnitroglycerin?
a) Atorvastatin
b) Metformin
c) Sildenafil
d) Omeprazole m-mANSWER-C.mSildenafil
Rationale:
SildenafilmtreatsmPAHm(pulmonarymarterialmhypertension) mbymrelaxingmthembloodmvesselsminmthemlungsmt
omallowmbloodmtomflowmeasily.
Same mas,mnitroglycerinmismamvaso-
dilatormwhichmismprimarilymtomtreatmanginalmchestmpainmandmtherebymitmreducesmbloodmpressure.
Remainingmdrugsmlikemomeprazolemandmatorvastatinmcanmbemgivenmformpatientsmwithminm24hrsmof mnitro
glycerinmadministration.
Amnurse mismcaringmformamclientmwhomhasmamnewmprescriptionmformnitroglycerin.mThemnursemshouldmmonito
rmformwhichmof mthe mfollowingmadverse meffectsmof mthe mmedication?
Nocturia
IncreasedmsalivamproductionmFlushi
ng
Feverm-mANSWER-Flushing
Rationale:
nitroglycerinmismamvaso-dilator.mWhenmvaso-dilatorsmtoomwell,mfluidmstartmsippingmoutmandmcausingmflushing
, Amnurse mismpreparingmtomobtainmampostprandialmbloodmglucose mlevelmfrommamclientmwhomhasmdiabetesmme
llitus.mWhichmofmthe mfollowingmactionsmshouldmthe mnurse mtake?
a) Applymthe mfirstmdropmofmbloodmtomthe mtestmstrip.
b) Cleanmthe mclient'smfingermwithmhexachlorophene.
c) Prickmthe mcentralmtipmofmthe mclient'smfinger.
d) Holdmthe mclient'smfingerminmamdependentmposition.m-mANSWER-
D.mHoldmthe mclient'smfingerminmamdependentmposition.
Rationale:
The mnurse mshouldmcleanmthemclient'smfingermwithmanmalcoholmswabmandmprickmthemsidemofmthemfinger,mnot
m the m centralm tip, m tom obtain m am postprandialm blood m glucose m level.
The mnurse mshouldmnotmapplymthemfirstmdropmof mbloodmtomthemtestmstripmsincemthemalcoholmcouldmcausemfal
se mreading.
Hexachlorophene mismnotmrecommendedmformcleaningmthe mclient'smfingermasmitmcanmcause mtissue mdamage.
TEST
Amnurse mismreinforcingmteachingmwithmamclientmaboutmbreastmself-
examinations.mWhichmofmthemfollowingmstatementsmbymthemclientmindicatesmanmunderstandingmof mthe mtea
ching?
a) "Itmismcommonmformone mbreastmtombe mlargermthanmthe mother."
b) "Itmismcommonmformthe mskinmonmmymbreastsmtomdimple."
c) "Imwillmperformmbreastmexamsmthe mdaymmymperiodmbegins."
d) "Imwillmperformmbreastmexamsmeverymothermmonth."m-mANSWER-
A.m"Itmismcommonmformone mbreastmtombe mlargermthan
the mother."
Rationale:
Itmismnormalmtomhave masymmetricalmbreasts,musually,mthe mleftmbreastmismbiggermthanmthe mright.
Thismismbecausemof mthemdifferenceminmthempercentagemofmbreastmtissuesmandmfattymtissues,mthat'smwhymth
eymreactmdifferentlymtomhormonalmchanges.
"Dimplingmonmthe mskinmonmbreastsmismNOTmcommon"mPhysicianmconsultationmshouldmbemtakenmregardingm
thismasmitmcanmbe mamsignmof mbreastmcancer.
"Self-
breastmexamsmare mrecommendedmtombemperformedmaftermamweekmwhenmthemperiodmstarts."mThe mrestmofm
the mmonthmbreastsmreamainmtendermdue mtomhormone mfluctuation.
m m m m m m m m
M & PRACTICE EXAMS 250 QUESTIONS AND CORREC
m m m m m m m
T DETAILED ANSWERS (VERIFIED
m m m
ANSWERS) WITH RATIONALES |ALREADY GRADED A
m m m m m
+
Amnursemismcaringmformamclientmwhomismtakingmlithiummandmreportsmpersistentmnauseamandmvomitingmform2
m days.m Whichmofm them followingm laboratorym valuesmshouldm them nursem reportm tom them provider?m -
m ANSWER-D. m Sodiumm 132m mEq/L
Rationale:
The mnurse mshouldmidentifymthatmamsodiummlevelmofm132mmEq/Lmismnotmwithinmthemexpectedmreference mra
nge mofm136mtom145mmEq/L.mThismfindingmindicatesmhyponatremia,mwhichmcanmleadmtomlithiummaccumulati
onmandmplacesmthemclientmatmriskmformlithiummtoxicity.mThemnursemshouldmreportmthismfindingmtomthemprov
ider.
Amnurse mismcaringmformamclientmwhomhasmcancermandmhasmamWBCmcountmofm4,000/mm3.mWhichmofmthe mfoll
owingmactionsmshouldmthe mnurse mtake?m-mANSWER-
A.mCleanse mthe mclient'smtoothbrushmwithmhydrogenmperoxide.
Rationale:
AmWBCmcountmofm4,000/mm3mismconsideredmlowmandmismknownmasmleukopenia.mAmlowmWBCmcountmcan
m be m causedm by mcancerm orm cancermtreatment. mThemnurse mshouldminstructmthemclientmtomcleanse mtheirmto
othbrushmwithmhydrogenmperoxide.mPeoplemwithmleukemiamormleukopeniamshouldmavoidmusingmdisposa
ble mrazors,mwhichmcanmcausemcutsmandmbleedingmthatmcanmleadmtominfections.mInstead,mtheymrecomme
ndmusingmanmelectricmrazormtomreduce mthemriskmofminjury.mEncouragingmthemclientmtomeatmunpasteurized
m dairy m products m is
notmrecommendedmasmtheymcanmcontainmharmfulmbacteriamthatmcanmcauseminfections.mDecreasingmthe mcli
ent'smproteinmintakemismnotmrecommendedmasmproteinmismimportantmformwoundmhealingmandmimmune mfu
nction
TEST
Amnurse mentersmamclient'smroommandmseesmsmokemcomingmfrommthembathroom.mWhichmofmthemfollowin
gmactionsmshouldmthe mnurse mtake mfirst?
a) Activate mthe mfire malarmmsystem.
b) Use mamfire mextinguishermatmthemsource mofmt
he msmoke.
c) Assistmthe mclientmtomamnearbymcommonmarea.
d) Close mthe mdoorsmtomthe mroommandmtomthe
,bathroom.m-mANSWER-C.mAssistmthe mclientmtomamnearbymcommonmarea.
Rationale:
use mRescu
e mAlarmmC
ontainmExt
inguish
TEST
Amnurse mismcontributingmtomthemplanmofmcare mformamclientmwhomreportsmdifficultymeatingmduemtomchronic
m arthritis. m Whichm of m the m followingm interventions m should m the m nurse m include m inm the m plan?
a) Applymfoammhandlesmtomthe mclient'smeatingmutensils.
b) Obtainmamreferralmformphysicalmtherapy.
c) Have manmassistive mpersonnelmfeedmthe mclient.
d) Askmthe mprovidermformamprescriptionmformampureedmdiet.m-mANSWER-
A.mApplymfoammhandlesmtomthe mclient'smeatingmutensils.
Rationale:
Tomhelpmamclientmwithmchronicmarthritismwhomexperiencesmdifficultymeating,mapplyingmfoammhandlesmtomth
e meatingmutensilsmcanmprovidemamlarger,mmore mcomfortablemgripmandmreducemstrainmonmthemjoints.mAskin
gmformampureemdietmmaymnotmbemnecessarymunlessmswallowingmdifficultiesmarempresent.mHavingmanmassisti
ve mpersonnelmfeedmthemclientmmaymnotmpromotemindependence.mWhile mobtainingmamreferralmformphysical
m therapy m maym bembeneficialm formoverallm mobility, m itmdoesmnotm directly m address mthem client'sm difficulty mwit
hmeating.
Amnurse mismprovidingmdirectionsmtomanmassistive mpersonnelmaboutmmovingmamclientmupminmbed.
a. "Place mampillowmundermthe mclient'smheadmpriormtomrepositioning."
b. "Keepmyourmfeetmclosemtogethermwhile mmovingmthe mclie
nt"mcm"Face minmthemdirectionmof mthe mclient'smmovement"
d.m"Move mthe mclient'smarmsmtomhismsidesmpriormtomrepositioning."m-mANSWER-
C.m"Face minmthe mdirectionmofmthe mcliet'smmovement."
Rational:
Whenmmovingmamclientmupminmbed,mitmismimportantmformthemnursemtomfaceminmthe mdirectionmof mthemclient's
m movementm tom maintain m properm body m mechanics m andm ensure m safe m transfer.
,1) Adjustm the m headm of m the m bedm tom am flatm position.
2) Remove m allm pillowsm fromm underm the m client.
3) Positionm the m UAPm onm the m side m opposite m the m nurse.
4) Place m am friction-reducingm sheetm underm the m client.
5) Askm the m clientm tom bendm the m legsm andm place m the m chinm onm the m chest.
6) Graspm the m sheetm andm move m the m clientm onm the m countm of m three.
Amnurse mismobtainingmammedicationmhistorymfrommamclientmwhomismtomstartmtakingmnitroglycerinmformchest
m discomfortm withmactivity. mWhichmofmthem followingmmedications mshouldmthe mnursem instructmthemclientmtom
avoidmtakingmwithinm24mhrsmofmusingmnitroglycerin?
a) Atorvastatin
b) Metformin
c) Sildenafil
d) Omeprazole m-mANSWER-C.mSildenafil
Rationale:
SildenafilmtreatsmPAHm(pulmonarymarterialmhypertension) mbymrelaxingmthembloodmvesselsminmthemlungsmt
omallowmbloodmtomflowmeasily.
Same mas,mnitroglycerinmismamvaso-
dilatormwhichmismprimarilymtomtreatmanginalmchestmpainmandmtherebymitmreducesmbloodmpressure.
Remainingmdrugsmlikemomeprazolemandmatorvastatinmcanmbemgivenmformpatientsmwithminm24hrsmof mnitro
glycerinmadministration.
Amnurse mismcaringmformamclientmwhomhasmamnewmprescriptionmformnitroglycerin.mThemnursemshouldmmonito
rmformwhichmof mthe mfollowingmadverse meffectsmof mthe mmedication?
Nocturia
IncreasedmsalivamproductionmFlushi
ng
Feverm-mANSWER-Flushing
Rationale:
nitroglycerinmismamvaso-dilator.mWhenmvaso-dilatorsmtoomwell,mfluidmstartmsippingmoutmandmcausingmflushing
, Amnurse mismpreparingmtomobtainmampostprandialmbloodmglucose mlevelmfrommamclientmwhomhasmdiabetesmme
llitus.mWhichmofmthe mfollowingmactionsmshouldmthe mnurse mtake?
a) Applymthe mfirstmdropmofmbloodmtomthe mtestmstrip.
b) Cleanmthe mclient'smfingermwithmhexachlorophene.
c) Prickmthe mcentralmtipmofmthe mclient'smfinger.
d) Holdmthe mclient'smfingerminmamdependentmposition.m-mANSWER-
D.mHoldmthe mclient'smfingerminmamdependentmposition.
Rationale:
The mnurse mshouldmcleanmthemclient'smfingermwithmanmalcoholmswabmandmprickmthemsidemofmthemfinger,mnot
m the m centralm tip, m tom obtain m am postprandialm blood m glucose m level.
The mnurse mshouldmnotmapplymthemfirstmdropmof mbloodmtomthemtestmstripmsincemthemalcoholmcouldmcausemfal
se mreading.
Hexachlorophene mismnotmrecommendedmformcleaningmthe mclient'smfingermasmitmcanmcause mtissue mdamage.
TEST
Amnurse mismreinforcingmteachingmwithmamclientmaboutmbreastmself-
examinations.mWhichmofmthemfollowingmstatementsmbymthemclientmindicatesmanmunderstandingmof mthe mtea
ching?
a) "Itmismcommonmformone mbreastmtombe mlargermthanmthe mother."
b) "Itmismcommonmformthe mskinmonmmymbreastsmtomdimple."
c) "Imwillmperformmbreastmexamsmthe mdaymmymperiodmbegins."
d) "Imwillmperformmbreastmexamsmeverymothermmonth."m-mANSWER-
A.m"Itmismcommonmformone mbreastmtombe mlargermthan
the mother."
Rationale:
Itmismnormalmtomhave masymmetricalmbreasts,musually,mthe mleftmbreastmismbiggermthanmthe mright.
Thismismbecausemof mthemdifferenceminmthempercentagemofmbreastmtissuesmandmfattymtissues,mthat'smwhymth
eymreactmdifferentlymtomhormonalmchanges.
"Dimplingmonmthe mskinmonmbreastsmismNOTmcommon"mPhysicianmconsultationmshouldmbemtakenmregardingm
thismasmitmcanmbe mamsignmof mbreastmcancer.
"Self-
breastmexamsmare mrecommendedmtombemperformedmaftermamweekmwhenmthemperiodmstarts."mThe mrestmofm
the mmonthmbreastsmreamainmtendermdue mtomhormone mfluctuation.
