ATI RN
ATI RN Pediatric Nursing 2023 II Questions
Extract:
Question 1 of 5
A nurse is prioritizing care for four clients. Which of the following clients should the nurse assess first?
Correct Answer: C
Rationale: The correct answer is C: An adolescent who has sickle cell anemia and slurred speech. This client should be assessed first because slurred speech could indicate a potential stroke, a life-threatening complication of sickle cell anemia. The nurse needs to act quickly to rule out this serious condition and initiate appropriate interventions.
Choices A, B, and D, while important, do not pose immediate life-threatening risks compared to the potential stroke in choice C. Care for the toddler with osteomyelitis can be safely delayed for a brief period, the adolescent in skin traction can be managed with pain medications until the nurse assesses the client with slurred speech, and the toddler with a burn can wait for the dressing change while the nurse addresses the urgent situation with the adolescent.
Question 2 of 5
A nurse is planning care for a child who has a prescription to transfuse 2 units of packed RBCs. Which of the following interventions should the nurse include in the plan of care?
Correct Answer: A
Rationale:
Correct
Answer: A - Infuse the packed RBC within 4 hours.
Rationale: Infusing packed RBCs within 4 hours is crucial to ensure the effectiveness and safety of the transfusion. Prolonged infusion time can lead to hemolysis and decrease the viability of the RBCs. It is essential to follow the prescribed rate of infusion to prevent adverse reactions and complications.
Summary of Incorrect
Choices:
B: Infusing dextrose 5% in water during the infusion of packed RBCs is unnecessary and can potentially lead to dilution of the RBCs, affecting their therapeutic effect.
C: Storing the second unit of blood at room temperature for up to 2 hours is incorrect as blood products should be stored according to specific guidelines to maintain their integrity and prevent bacterial growth.
D: Administering RBCs using non-filtered IV tubing can introduce contaminants into the bloodstream, leading to infection or adverse reactions. It is essential to use filtered IV
Question 3 of 5
A nurse is caring for a 4-year-old child who has meningitis and is receiving gentamicin. Which of the following laboratory values should the nurse report to the provider?
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.
Question 4 of 5
A nurse is providing teaching to the parents of a school-age child newly diagnosed with a seizure disorder. The nurse should teach the parents to take which of the following actions during a seizure?
Correct Answer: B
Rationale: The correct answer is B: Clear the area of hard objects. During a seizure, the child may thrash around uncontrollably, posing a risk of injury if there are hard objects nearby. By clearing the area of such objects, the parents can help prevent the child from harming themselves during the seizure. Placing the child in a prone position (choice
A) is not recommended as it can obstruct breathing. Inserting a tongue blade between the teeth (choice
C) is also not advised as it can cause injury to the child's mouth during the seizure. Minimizing movement of the limbs (choice
D) is important to prevent injury, but clearing the area of hard objects takes precedence.
Question 5 of 5
A school nurse is assessing a 7-year-old student. The nurse should identify which of the following findings as a potential indicator of physical abuse?
Correct Answer: D
Rationale: The correct answer is D: Bruising around the wrists. This finding is concerning for physical abuse because bruises around the wrists are not commonly seen in accidental injuries. These bruises may indicate that the child was grabbed or restrained forcefully. It is crucial for the nurse to further assess the nature, location, and pattern of the bruising to determine if it raises suspicion of abuse. Abrasions on the knees (choice
A) are more likely to be related to normal childhood activities. Front deciduous teeth missing (choice
B) is a common occurrence in children due to natural tooth loss. Weight in the 45th percentile (choice
C) is within the normal range and does not specifically indicate physical abuse.