ATI RN Nursing Care of Children 2019 | Nurselytic

Correct Answer: D

Rationale: The correct action for the nurse to take first is to prepare the toddler for nasotracheal intubation (Option
D). This is the most urgent response because the toddler is presenting with severe dyspnea and drooling, which are signs of airway compromise. Nasotracheal intubation is necessary to secure the airway and ensure adequate oxygenation and ventilation. Administering an antibiotic (Option
A) or obtaining a blood culture (Option
B) may be necessary later but addressing the airway is the priority. Inserting an IV catheter (Option
C) can be done after securing the airway.
Therefore, preparing for nasotracheal intubation is the most critical and life-saving action in this scenario.

Correct Answer: A

Rationale: The correct answer is A: Assess respiratory status. This is the first action the nurse should take as airway and breathing are the top priorities in any emergency situation. Ensuring the child has a patent airway and is breathing adequately is crucial for their survival. Assessing respiratory status includes observing for signs of distress, such as increased respiratory rate, use of accessory muscles, and abnormal breath sounds. This initial assessment will help the nurse determine the child's immediate needs and guide further interventions.

Inspecting for fluid leaking from the ears (
B) and examining the scalp for lacerations (
C) are important assessments but should come after ensuring the child's respiratory status is stable. Checking pupil reactions (
D) is also important but not as immediate as assessing respiratory status in this scenario.

Correct Answer: C

Rationale: The correct answer is C: Bruising around the wrists. This is a potential indicator of physical abuse because bruising around the wrists suggests that the child may have been grabbed or restrained forcefully. It is important to note that bruising in unusual or suspicious locations, such as around the wrists, is often associated with physical abuse. The other choices are not specific indicators of physical abuse.
Choice A (Weight in 45th percentile) is a normal growth parameter and does not directly suggest physical abuse.
Choice B (Abrasions on the knees) could be indicative of a fall or accident rather than physical abuse.
Choice D (Front deciduous teeth missing) is a dental issue and not typically associated with physical abuse in isolation.

Correct Answer: C

Rationale: The correct answer is C: Check the pH of the gastric secretions. This should be done first to confirm proper tube placement in the stomach, ensuring that feeding won't be delivered into the lungs by mistake, which can be dangerous. If the pH is acidic (pH <5), it indicates the tube is in the stomach. Flushing the tube with water (
A) should only be done after confirming placement. Attaching the feeding bag tubing (
B) and setting the administration rate (
D) should also be done after confirming proper placement.

Correct Answer: A

Rationale: The correct answer is A: "You will need to keep your leg straight for 8 hours following the procedure." This is important because maintaining the leg straight helps prevent bleeding from the catheter insertion site. Keeping the leg straight for 8 hours allows the blood vessel to heal and prevents complications.

Explanation for incorrect choices:
B: Having the dressing removed 12 hours after the procedure is not accurate as the dressing is typically removed after a few hours to assess the insertion site.
C: Being on a clear liquid diet for 24 hours is not necessary for this procedure as it does not directly impact the outcome.
D: Being on bed rest for 2 days after the procedure is excessive and not recommended as early mobilization is encouraged to prevent complications.