ATI RN
ATI RN Pediatric Nursing 2023 I Questions
Extract:
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%. Laboratory Results: Chest x-ray: mild left ventricular hypertrophy is noted. Increased pulmonary vascular markings are noted in all lobes.
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.
Correct Answer: C (Condition), A,B (Actions), B,C (Parameters)
Rationale: Action to Take: Provide chest physiotherapy and postural drainage, Elevate the head of the bed to a 45° angle; Potential Condition: Respiratory syncytial virus bronchiolitis; Parameter to Monitor: Intake and output, Respiratory status.
Rationale: For a client most likely experiencing respiratory syncytial virus bronchiolitis, the nurse should provide chest physiotherapy and postural drainage to help clear secretions and elevate the head of the bed to improve breathing. Monitoring intake and output helps assess hydration status, and monitoring respiratory status is crucial in evaluating the client's response to treatment and progression of the condition.
Incorrect choices: A includes conditions unrelated to the client's symptoms. B involves actions for different conditions and medications. C includes parameters not directly related to the potential condition.
Extract:
Question 2 of 5
A nurse is providing teaching about injury prevention to the parents of a toddler. Which of the following safety measures should the nurse include in the teaching?
Correct Answer: A
Rationale: The correct answer is A: Check clothing for loose buttons. This is important because loose buttons can pose a choking hazard to toddlers. By checking and securing clothing items, parents can prevent accidental ingestion.
Choice B is incorrect as the recommended water heater temperature for safety is 49°C (120°F), not 54°C.
Choice C is relevant for preventing falls but not directly related to injury prevention from choking hazards.
Choice D is incorrect because balloons are a choking hazard for young children.
Question 3 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, it is important to ensure the safety of the individual by removing any nearby hard objects that could cause injury. Placing the child in a prone position (choice
C) is not recommended as it can lead to airway obstruction. Minimizing movement of the limbs (choice
A) is also not necessary as it may not be possible to control the child's movements during a seizure. Inserting a tongue blade between the teeth (choice
D) is dangerous and can cause harm.
Therefore, the best action to take during a seizure is to clear the area of hard objects to prevent injury.
Question 4 of 5
A nurse is assessing a 5-month-old infant. Which of the following findings should the nurse report to the provider?
Correct Answer: B
Rationale: The correct answer is B: Exhibits head lag when pulled to a sitting position. This finding is concerning because by 5 months, infants should have minimal head lag when pulled to a sitting position, indicating poor head control, which could be a sign of developmental delay or neurological issue. A: Unable to roll from back to abdomen is a milestone achieved around 5-6 months and not a cause for concern at this age. C: Unable to hold a bottle is typically seen around 6-7 months and is not a critical concern at 5 months. D: Absent grasp reflex is normal at this age as the grasp reflex typically disappears by 3-4 months.
Extract:
Cerebrospinal fluid: Pressure: 22 cm H2O (less than 20 cm H2O), Color: Cloudy (clear or colorless), Blood: None (none), Cells RBC: 0 (0), WBC: 36 cells/mcL (0 to 30 cells/mcL), Protein: 92 mg/dL (up to 70 mg/dL), Glucose: 36 mg/dL (50 to 75 mg/dL), Serum glucose: 64 mg/dL (60 to 100 mg/dL).
Question 5 of 5
Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct action for the nurse to take is to administer ceftriaxone (choice
A). This is the correct answer because ceftriaxone is an antibiotic commonly used to treat bacterial infections, especially in cases of suspected sepsis or meningitis. Administering it promptly can help prevent the spread of infection and improve the patient's condition.
The other choices are incorrect because:
B: Administering a pneumococcal conjugate vaccine is not the immediate priority in this scenario where treatment for an existing infection is needed.
C: Initiation of serum glucose testing every 1 hr is not indicated without further context or rationale provided in the question.
D: Initiating neutropenic precautions is not necessary based on the information provided and is not a direct action to address the immediate issue at hand.