RN ATI Pediatric Nursing Exam (70 NGN Questions with Answers) -Nurselytic

Correct Answer: A

Rationale:
Correct Answer: A - Provide for periods of rest.


Rationale: It is important for the nurse to include information about providing periods of rest in the teaching because rest is essential for recovery and healing. Rest allows the body to conserve energy, reduce stress, and promote overall well-being. By including this information, the nurse is promoting the child's health and supporting the healing process.

Summary of other choices:
B: Increasing oxygen flow rate until cyanosis resolves can lead to oxygen toxicity and is not a safe or appropriate intervention.
C: Withholding digoxin based solely on pulse rate without considering other factors or consulting the healthcare provider can be dangerous and potentially harmful.
D: Weighing the child once a month is important for monitoring growth and nutrition, but it is not directly related to the immediate care and teaching needed in this scenario.

Correct Answer: B

Rationale: The correct answer is B: Urine output of 15 mL in the last 2 hr. Inadequate urine output can indicate renal impairment or inadequate fluid intake. This is a critical finding that needs immediate attention to prevent further complications like acute kidney injury. A: Drainage from the chest tube of 22 mL in the last hour is within the normal range. C: Skin temperature of 36°C (96.8°F) is within normal limits. D: Pedal and posterior tibial pulses of 2+ indicate normal circulation.

Correct Answer: D

Rationale: The correct answer is D: Tachypnea. Tachypnea, which is rapid breathing, can indicate respiratory distress or an underlying serious condition that requires immediate attention. Reporting this finding promptly is crucial to ensure timely intervention. Rhinorrhea, pharyngitis, and coughing are common symptoms that may not require urgent attention as they can be managed symptomatically. In summary, tachypnea is the most concerning symptom that warrants immediate reporting, while the other choices are less urgent and can be addressed in due course.

Correct Answer: B

Rationale: The correct answer is B: Exhibits head lag when pulled to a sitting position. This finding indicates poor head control, a developmental milestone typically achieved around 4 months. Reporting this to the provider is crucial for further assessment and intervention.
Choice A is incorrect as rolling from back to abdomen is typically achieved around 5-6 months.
Choice C is incorrect as holding a bottle is a milestone around 6-10 months.
Choice D is incorrect as the grasp reflex typically disappears around 3-4 months. The key is to identify the finding that deviates significantly from the expected developmental milestone, which is demonstrated by choice B.

Correct Answer: C

Rationale: The correct choice is C. The nurse should assess the adolescent with sickle cell anemia and slurred speech first because slurred speech could indicate a potential stroke or other serious neurological complication related to sickle cell disease. It is crucial to prioritize neurological symptoms as they may lead to life-threatening complications if not addressed promptly. Assessing for signs of stroke and providing immediate intervention is essential in this situation.

Choices A, B, and D involve pain management and wound care, which are important but not as urgent as addressing potential neurological complications.
Therefore, assessing the client with slurred speech is the priority to ensure timely and appropriate intervention.