ATI RN
ATI Nur 223a Sect 4 Pediatrics Final Exam Questions
Extract:
Medical History: Diagnosis: Bilateral pneumonia, Past medical history: Cystic fibrosis, Plan: Aggressive airway clearance therapy, intravenous antibiotic therapy. Nurses Notes: 0700 hrs: Caregiver reports child has had increased coughing, fatigue, and a poor appetite for the past several days. Wheezing and rhonchi auscultated bilaterally. Respirations labored with accessory muscle use. Frequent cough productive with thick, yellow blood-streaked sputum. Dyspnea noted with activity. Child reports “a bit of a stomachache†and rates the discomfort as 3 on a scale of 0 to 10. Abdomen soft and non-tender to palpation. Active bowel sounds auscultated. 0900 hrs: Respirations rapid with accessory muscle use. Dyspnea noted while at rest. Frequent cough. Thick yellow sputum expectorated following airway clearance therapy. Child reports chest discomfort as 4 on a scale of 0 to 10. Child consumes approximately 50% of meals. Denies abdominal pain. Passed three large, frothy, foul-smelling stools. Vital Signs: 0700 hrs: Oral temperature: 39.1°C (102.4°F), Heart rate: 116/min, Respiratory rate: 32/min, Blood pressure: 102/60 mm Hg, Oxygen saturation: 95% on room air. 0900 hrs: Oral temperature: 38.1°C (100.6°F), Heart rate: 128/min, Respiratory rate: 32/min, Blood pressure: 88/48 mm Hg, Oxygen saturation: 88% on room air. Diagnostic Results: 0900 hrs: Chest X-ray: Bilateral infiltrates consistent with pneumonia, CBC: WBC: 15,000/mm³, Hemoglobin: 11 g/dL, Platelets: 250,000/mm³.
Question 1 of 5
Which of the following assessment findings should the nurse report to the provider? (Select all that apply)
Correct Answer: A,B,E
Rationale: The correct answers are A, B, and E. A low oxygen saturation of 88% on room air indicates poor oxygenation, which is a critical finding that should be reported to the provider promptly. A heart rate of 128/min is elevated and may indicate distress or an underlying issue that requires attention. Passing three large, frothy, foul-smelling stools can be a sign of gastrointestinal distress or infection, which also requires further evaluation. These findings indicate potential respiratory, cardiovascular, and gastrointestinal issues that need immediate medical attention.
Choices C and D are not immediate concerns that require urgent reporting to the provider.
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