ATI RN Pediatric Nursing 2023 II | Nurselytic

Correct Answer: C

Rationale: The correct answer is C: Creatinine 1.4 mg/dL (0.2 to 0.5 mg/dL). This value is elevated, indicating potential kidney dysfunction, which is a common adverse effect of gentamicin. The nurse should report this to the provider for further evaluation and possible adjustment of the medication dosage.

A: Creatinine 0.3 mg/dL is within the normal range.
B: BUN 12 mg/dL is within the normal range.
D: BUN 6 mg/dL is within the normal range.

In summary, the nurse should report an elevated creatinine level as it suggests possible kidney damage due to gentamicin. The other choices are within normal limits and do not warrant immediate attention.

Correct Answer: C

Rationale: The correct answer is C: Implement a 3 hr feeding schedule. In heart failure, infants may have difficulty feeding due to shortness of breath and fatigue. Implementing a 3-hour feeding schedule allows for adequate rest between feedings, reducing the risk of overwhelming the infant's cardiovascular system and promoting better feeding efficiency.


Choice A is incorrect because allowing the infant to self soothe by crying prior to feeding can lead to increased stress and may worsen the infant's heart failure symptoms.


Choice B is incorrect as placing the infant in a recumbent position during feeding can increase the workload on the heart and may lead to aspiration or choking.


Choice D is incorrect because allowing the infant 45 minutes for each feeding may lead to fatigue and may not be well tolerated by an infant with heart failure.

In summary,
Choice C is the correct option as it promotes adequate rest and optimal feeding for an infant with heart failure, while the other choices may pose risks or challenges for the infant's

Correct Answer: D

Rationale: The correct answer is D: Hyperpyrexia. Acetylsalicylic acid poisoning can lead to metabolic acidosis, which can cause hyperpyrexia (extremely high fever). This is due to the toxic effects on the central nervous system. Neck vein distention (
A) is not typically associated with acetylsalicylic acid poisoning. Jaundice (
B) is more commonly seen in liver toxicity. Polyuria (
C) is not a typical symptom of acetylsalicylic acid poisoning. In summary, hyperpyrexia is the most likely manifestation of acute acetylsalicylic acid poisoning in a preschool-age child, making it the correct answer.

Correct Answer: A

Rationale: The correct answer is A: Discard the first voided specimen. This is because the first voided specimen may contain substances that have accumulated overnight and are not representative of the 24-hour collection. It is important to start the collection after discarding the first void and then collect all subsequent voids over the next 24 hours.
Choice B is incorrect as voiding every hour is not necessary for a 24-hour urine collection.
Choice C is incorrect because cleansing with a povidone-iodine solution is not typically required for a urine collection.
Choice D is incorrect because saving the final specimen in a separate container is unnecessary and may lead to confusion.

Correct Answer: C

Rationale: The correct answer is C: Rounded abdomen. Necrotizing enterocolitis (NE
C) is a serious condition in infants characterized by inflammation and necrosis of the intestines. A rounded abdomen is a common finding in NEC due to abdominal distention from gas and fluid accumulation. Vomiting (
A) is a nonspecific symptom in infants and can occur in various conditions. Hypertension (
B) is not typically associated with NEC. Tachypnea (
D) can occur in NEC due to respiratory distress, but it is not a specific finding.