The nurse is preparing to assist in examining a Hispanic child who was brought to the clinic by the mother. During the assessment of the child, the nurse should take which action(s)?

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ATI RN Custom Exams Set 4 Questions

Question 1 of 5

The nurse is preparing to assist in examining a Hispanic child who was brought to the clinic by the mother. During the assessment of the child, the nurse should take which action(s)?

Correct Answer: C

Rationale: Building rapport with the child is essential to establish trust and cooperation during the assessment. Admiring the child may not be appropriate in a professional setting and might not contribute significantly to the assessment. Taking the child's temperature is a routine part of the assessment but may not be the most critical action in this scenario. Obtaining an interpreter is crucial to ensure effective communication between the healthcare team and the child and their mother, especially considering potential language barriers.

Question 2 of 5

Which situation(s) are classified as natural disasters?

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 3 of 5

A nurse administers albuterol to a child with asthma. For what common side effect should the nurse monitor the child?

Correct Answer: C

Rationale: The correct answer is C, Tachycardia. Albuterol, a bronchodilator used to treat asthma, commonly causes tachycardia as a side effect. This occurs due to the medication's stimulatory effect on beta-2 adrenergic receptors. Flushing (Choice A) is not a common side effect of albuterol. Dyspnea (Choice B) refers to difficulty breathing, which is a symptom albuterol aims to alleviate. Hypotension (Choice D) is not typically associated with albuterol use; instead, albuterol can lead to an increase in blood pressure.

Question 4 of 5

After attempting suicide by taking 200 acetaminophen (Tylenol) tablets, a client is transferred from the emergency department to the locked psychiatric unit. The client is now awake and alert but refuses to speak with the nurse. In this situation, what is the nurse's first priority?

Correct Answer: D

Rationale: The nurse's first priority in this situation is to ensure the client's safety by initiating suicide precautions. This involves removing any potential means of self-harm and closely monitoring the client to prevent further attempts. While establishing rapport and communication are important, safety is paramount at this critical juncture. Placing the client in full restraints should be avoided unless absolutely necessary for immediate safety concerns.

Question 5 of 5

The nurse is caring for a client who goes into ventricular tachycardia. Which intervention should the nurse implement first?

Correct Answer: B

Rationale: The correct first intervention when a client goes into ventricular tachycardia is to assess for a pulse. This is crucial as the presence or absence of a pulse guides subsequent actions. Initiating chest compressions or calling a code should only be done after confirming the absence of a pulse. Continuing to monitor the client without checking for a pulse delays potentially life-saving interventions.

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