ATI RN
ATI RN Pediatric Nursing 2023 Exam 3 Questions
Extract:
Question 1 of 5
A nurse is evaluating the pain level of a toddler who is cognitively impaired to a nonpharmacologic intervention. Which of the following pain scales should the nurse use to evaluate the toddler's pain level?
Correct Answer: C
Rationale: The correct answer is C: FLACC. FLACC stands for Face, Legs, Activity, Cry, and Consolability and is a pain assessment tool specifically designed for nonverbal or cognitively impaired individuals like toddlers. The tool assesses the toddler's facial expressions, leg movements, activity level, crying, and ability to be consoled. This comprehensive evaluation helps the nurse accurately determine the toddler's pain level. Visual analog scale (
A) and FACES scale (
B) require the ability to communicate and understand abstract concepts, making them unsuitable for cognitively impaired toddlers. CRIES scale (
D) is primarily used for infants and may not be as effective for toddlers.
Question 2 of 5
A nurse is teaching the parent of an infant who has a new diagnosis of heart failure about nutrition. Which of the following instructions should the nurse include in the teaching?
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 increased work of breathing. Implementing a 3 hr feeding schedule ensures the infant has enough time to rest and conserve energy between feedings, reducing the risk of fatigue and respiratory distress.
Choices A and D are incorrect as they do not address the specific needs of an infant with heart failure.
Choice B is incorrect as placing the infant in a recumbent position during feeding can worsen respiratory distress.
Extract:
History and Physical: A 15-year-old adolescent is admitted for a vaso-occlusive crisis. The parent reports that the adolescent has a low-grade fever and has vomited for 3 days. The adolescent reports having right-sided and low back pain. They also report hands and right knee are painful and swollen. The client reports pain as 8 on a scale of 0 to 10. Vital signs: Temperature 37.8 C (100 F), Heart rate 100/min, Blood pressure 110/72 mm Hg, Respiratory rate 20/min, Oxygen saturation 95% on room air. Assessment: Awake, alert, and oriented X 3, Yellow sclera of eyes noted bilaterally, Right upper quadrant tender to palpation, Hands painful to touch and swollen bilaterally, Right knee is swollen, warm to palpation, and client reports pain as 8 on a scale of 0-10, Client is tearful and grimacing during the examination. Laboratory Results: Hct 28% (32% to 44%), Hgb 6g/dL (10 to 15.5 g/dL), WBC count 20,000/mm3 (6,200 to 17,000/mm3), ALT 50 units/L (4 to 36 units/L), AST 62 units/L (10 to 40 units/L), Total bilirubin 3.0 mg/dL (0.3 to 1.0 mg/dL), Chest radiographic examination indicates cardiomegaly and systolic murmur
Question 3 of 5
The nurse is planning care for the adolescent. Select the 5 interventions the nurse should include.
Correct Answer: A,C,D,E,G
Rationale: The correct interventions are A, C, D, E, and G. A: Monitoring oxygen saturation is crucial for assessing respiratory status. C: Giving oral hydroxyurea is essential for managing sickle cell disease. D: Administering meperidine IV for pain control is appropriate. E: Ensuring the pneumococcal vaccine is current helps prevent infections. G: Administering folic acid is part of managing sickle cell disease. Summary: B is incorrect as restricting oral intake may worsen dehydration. F is incorrect as strict bed rest is not recommended for adolescents.
Extract:
Question 4 of 5
A nurse is assessing a child who is 2 hr postoperative following a cardiac catheterization and finds the dressing is saturated with blood. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Apply pressure just above the insertion site. This action is crucial to control the bleeding and prevent further complications. Applying pressure directly over the site helps to stop the bleeding and stabilize the child's condition. Monitoring the pulse distal to the insertion site (
B) is important but secondary to stopping the bleeding. Obtaining vital signs (
C) can wait until the bleeding is controlled. Reinforcing the dressing (
D) is not the priority as the dressing is already saturated with blood.
Question 5 of 5
A nurse is planning care for a child who is in the acute stage of nephrotic syndrome. Which of the following interventions should the nurse include in the plan of care?
Correct Answer: A
Rationale: The correct answer is A: Weigh the child once per day. In nephrotic syndrome, monitoring weight daily is crucial to assess fluid status and response to treatment. Weight gain indicates fluid retention, a common complication. Positioning the child supine (
B) is not relevant. Calorie intake should be sufficient to meet increased metabolic demands, so limiting it to 45 cal/kg/day (
C) is incorrect. Increasing fluid intake to 2 L/day (
D) may worsen fluid overload.