ATI RN Pediatrics 2023 | Nurselytic

Correct Answer: A

Rationale: The correct answer is A: Urine output of 15 mL in the last 2 hr. In a postoperative pediatric patient, a low urine output can indicate inadequate renal perfusion, which could be a sign of decreased cardiac output or dehydration. This finding is crucial to report to the provider as it may indicate a need for intervention to optimize the patient's fluid status and cardiac function.
The other choices are incorrect because:
B: Pedal and posterior tibial pulses of 2+ indicate adequate peripheral perfusion.
C: Skin temperature of 36°C is within the normal range for pediatric patients.
D: Drainage from the chest tube of 22 mL in the last hour is expected postoperatively and does not indicate an immediate concern.
In summary, the low urine output is the most critical finding that requires immediate attention to ensure the toddler's optimal recovery and well-being.

Correct Answer: B

Rationale: The correct answer is B: Urine output 256 mL over 8 hr. In nephrotic syndrome and postoperative open-heart surgery, monitoring urine output is crucial to assess kidney function and fluid balance. A urine output of 256 mL over 8 hours indicates adequate kidney perfusion and function, suggesting effective management.
A: Temperature within normal range does not directly indicate effectiveness of management.
C: No pain with voiding is important but does not specifically indicate effectiveness of management for nephrotic syndrome or postoperative care.
D: Odorless urine is a good sign but does not directly reflect the effectiveness of managing nephrotic syndrome or postoperative care.

Correct Answer: C

Rationale: The correct answer is C: Lavender. Lavender oil is known for its calming and relaxing properties, making it suitable for children to help with relaxation. It is gentle and safe to use, promoting a sense of calmness. Tea tree (
A) and eucalyptus (
B) oils are more commonly used for their antiseptic and respiratory benefits, not specifically for relaxation. Jasmine (
D) oil is known for its uplifting and floral scent, which may not be as soothing for relaxation compared to lavender.

Correct Answer: B

Rationale: The correct answer is B: Stevens-Johnson syndrome. Cefazolin belongs to the class of antibiotics known as cephalosporins, which can rarely cause severe skin reactions like Stevens-Johnson syndrome. This syndrome presents with flu-like symptoms followed by a painful red or purplish rash that spreads and blisters. It is a serious and potentially life-threatening reaction that requires immediate medical attention. The other options are not typically associated with cefazolin. Hypotension is more commonly seen with medications like vasopressors, prolonged wound healing is not a known side effect of cefazolin, and bradypnea is not a typical adverse effect of this medication. Monitoring for Stevens-Johnson syndrome is crucial to promptly identify and manage this severe reaction.

Correct Answer: D

Rationale: The correct answer is D: Initiate droplet precautions. This is the first action the nurse should take because epiglottitis is a medical emergency with the potential for rapid airway compromise. By initiating droplet precautions, the nurse can help prevent the spread of infection to others while also protecting themselves. Obtaining an x-ray (choice
A) or administering antibiotics (choice
C) can be important interventions but should not take precedence over protecting the airway. Placing intubation equipment (choice
B) at the bedside may be necessary but is not the first action to prioritize in this situation.