ATI RN
Essential of Pediatric Nursing Test Bank Questions
Question 1 of 5
A client is admitted with a serum glucose of 618mg/dl. The client is awake and oriented, with hot, dry skin; a temperature of 100.6F (38.1 C); a heart rate of 116beats/min; and a blood pressure of 108/70mmHg. Based on these findings, which nursing diagnosis takes highest priority?
Correct Answer: A
Rationale: The highest priority nursing diagnosis in this scenario is Deficient fluid volume related to osmotic diuresis. The client's serum glucose level of 618mg/dl indicates severe hyperglycemia, which is likely causing osmotic diuresis leading to fluid volume deficit. The client's hot, dry skin, along with a heart rate of 116 beats/min, and blood pressure of 108/70mmHg are symptoms of dehydration due to fluid loss. If left untreated, deficient fluid volume can lead to serious complications such as hypovolemic shock. Therefore, addressing the fluid volume deficit is essential to stabilize the client's condition before other nursing diagnoses are addressed.
Question 2 of 5
The nurse is assessing a 3-month-old during a well-baby visit. Which of the following findings would warrant the nurse to recommend that the baby have an ultrasound for a possible diagnosis of developmental dysplasia of the hip (DDH)?
Correct Answer: B
Rationale: Developmental dysplasia of the hip (DDH) is a condition where the hip joint does not develop normally. It is important to detect DDH early in infants as it can lead to long-term hip problems. One of the key physical exam findings that may suggest DDH is unequal knee heights when the infant's legs are flexed. This is known as the Galeazzi sign, and it can indicate hip dysplasia or dislocation. Therefore, if a nurse observes this finding during an assessment of a 3-month-old infant, it would warrant recommending an ultrasound to further evaluate for possible DDH. Bilateral plantar flexion, bilateral polydactyly, and a positive Babinski test are not typically associated with DDH.
Question 3 of 5
When performing a newborn assessment, the nurse should measure the vital signs in the following sequence:
Correct Answer: A
Rationale: When performing a newborn assessment, it is important to measure the vital signs in the sequence of pulse, respirations, and temperature. This sequence is recommended because measuring the pulse first provides immediate information on the baby's cardiovascular status, followed by respirations to assess respiratory function, and ending with temperature which can be influenced by the other vital signs. This comprehensive approach helps ensure all vital signs are assessed accurately and in a logical order.
Question 4 of 5
Which of the following method if used by Wilma will best assure that the tracheostomy ties are not too tightly placed?
Correct Answer: A
Rationale: Placing 2 fingers between the tracheostomy tie and the neck is a reliable method to ensure that the tie is not too tight. This technique allows for proper circulation around the neck area and helps prevent skin irritation or pressure ulcers from developing. It strikes a balance between securing the tracheostomy in place and maintaining the patient's comfort and safety. Checking for appropriate tightness by using the finger method is a standard practice in tracheostomy care to prevent complications related to excessive pressure or constriction.
Question 5 of 5
Which laboratory results (besides hematuria) are most consistent with hemolytic uremic syndrome (HUS)?
Correct Answer: C
Rationale: HUS typically presents with mild proteinuria along with increased BUN and creatinine, reflecting impaired renal function.