ATI RN
ATI RN Pediatric Nursing 2023 Exam 3 Questions
Extract:
History and Physical: Infant was full-term at birth. Birth weight was 3.5 kg (7.7 lb). Infant is not gaining weight as expected. One week ago at outpatient visit, weight was 3.6 kg (7.9 lb). Parent reports for past 2 days infant is breathing faster during feedings and does not finish feedings. Parent also reports decreased appetite and puffiness around the infant's eyes. Parent states that the last wet diaper was about 10 hr ago. Infant admitted for diagnostic evaluation, failure to thrive, and nutritional/fluid support. Vital Signs: Admission: Temperature 37.7° C (99.9° F), Heart rate 174/min while sleeping, Respiratory rate 72/min while sleeping. Assessment: Respirations: Tachypneic with moderate retractions and nasal flaring. Upon auscultation, crackles heard in all lung fields. No nasal drainage noted. Dry cough noted periodically. Skin: Pallor, scalp is diaphoretic, lower extremities are cool to touch. Cardiac: Tachycardic, regular rhythm, no murmur is heard. Peripheral pulses are full and bounding in the upper extremities and weak bilateral pedal pulses are noted. Fluids: Mucous membranes are slightly dry and pink. Skin turgor is slightly decreased. Capillary refill is 3 seconds. Noted periorbital edema and nonpitting edema of feet. Anterior fontanel is soft and slightly depressed. Diaper remains dry. Abdomen: Soft, full, round, bowel sounds are present and active. Blood pressure in right upper extremity 60/39 mm Hg, Oxygen saturation 90%
Question 1 of 5
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Action to Take
Potential Condition
Parameter to Monitor
Correct Answer: C
Rationale: Action to Take: Provide chest physiotherapy and postural drainage; Potential Condition: Cystic fibrosis; Parameter to Monitor: Number of steatorrhea stools, Intake and output.
Rationale:
1. Cystic fibrosis is a genetic disorder that affects the lungs and digestive system, leading to thick mucus production. Chest physiotherapy and postural drainage help clear mucus from the lungs.
2. Monitoring the number of steatorrhea stools is important as it indicates malabsorption in cystic fibrosis. Intake and output monitoring helps assess hydration status and nutritional intake.
3. Pyloric stenosis, congestive heart failure, and respiratory syncytial virus bronchiolitis are not conditions typically associated with chest physiotherapy and postural drainage.
4. Anticipating a prescription for digoxin and implementing contact precautions are not relevant actions for addressing cystic fibrosis.
5. Monitoring for periorbital edema is
Extract:
Question 2 of 5
A nurse is reviewing safety measures with a group of parents to prevent burn injuries for toddlers. Which of the following safety measures should the nurse include in the teaching?
Correct Answer: B
Rationale: The correct answer is B: Keep electrical wires hidden from view. This is important to prevent toddlers from touching or playing with exposed wires, reducing the risk of electrical burns. Hiding wires helps ensure a safe environment.
Incorrect Answers:
A: Setting the water heater too high can scald a child, increasing the risk of burns.
C: Encouraging outdoor activities during peak sun hours can lead to sunburn, not burn prevention.
D: Turning pot handles towards the front of the stove can still be accessible to curious toddlers, increasing the risk of burns.
Question 3 of 5
A nurse is planning care for a child who has varicella. Which of the following interventions should the nurse plan to include?
Correct Answer: D
Rationale: The correct answer is D: Initiate airborne precautions. Varicella (chickenpox) is highly contagious and spreads through respiratory droplets. Airborne precautions help prevent the transmission of the virus to others. Providing a warm blanket (
A) is not directly related to managing varicella. Assessing for Koplik spots (
B) is associated with measles, not varicella. Administering aspirin for fever (
C) is contraindicated in varicella due to the risk of Reye's syndrome.
Question 4 of 5
A nurse is assessing a preschool-age child who is in the immediate postoperative period following a tonsillectomy. Which of the following assessment findings is the priority?
Correct Answer: D
Rationale: The correct answer is D: The child swallows frequently. This is the priority assessment finding post-tonsillectomy as it may indicate bleeding, which can be life-threatening. Swallowing frequently can suggest blood pooling at the surgical site, leading to hemorrhage. A prompt assessment and intervention are crucial to prevent further complications.
Choices A, B, and C are not as high priority because throat pain, refusal of clear liquids, and crying are common after tonsillectomy and do not pose immediate life-threatening risks.
Question 5 of 5
A nurse is preparing to assess a 4-year-old child's visual acuity. Which of the following actions should the nurse plan to take?
Correct Answer: D
Rationale: The correct answer is D, using a tumbling E chart for the assessment. This type of chart is commonly used for young children due to its simplicity - the child is asked to identify the direction the "E" is facing. This helps assess visual acuity accurately in children who may not yet know letters. Assessing both eyes together first (choice
A) may lead to inaccuracies. Positioning the child 4.6 meters away (choice
B) is too far for a child's assessment. Testing without glasses first (choice
C) may not provide an accurate baseline. Overall, using a tumbling E chart is the most appropriate method for assessing visual acuity in a 4-year-old child.