RN nursing care of children ATI
a nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy which of the following findings should the nurse expect sata - negative Babinski reflex - ankle clonus - exaggerated stretch reflexes - uncontrollable movements of the face - contractures
- ankle clonus - exaggerated stretch reflexes - contractures
a nurse is caring for a preschooler who has been receiving IV fluids via a peripheral IV catheter. When preparing to discontinue the IV fluids and cath, which of the following actions should the nurse plan to take (ORDER) - occlude the IV tubbing - remove the tape securing the catheter - turn off the IV pump - apply pressure over the catheter insertion site
- turn off the IV pump - occlude the IV tubbing - remove the tape securing the catheter - apply pressure over the catheter insertion site
a school nurse is preparing to administer atomoxetine 1.2 mg/kg/day po to a school age child who weighs 75 lb available is atomoxetine 40 mg/capsule how many capsules should the nurse administer per day
1 capsule - 75/2.2= 34.09 - 1.2 x 34.00= 40.90 - 40.90/40= 1
a nurse is receiving change-of-shift report for four children which of the following children should the nurse see first - a school-age child who has sickle cell anemia and reports decreased vision in the left eye - a school-age child who has cystic fibrosis and a frequent nonproductive cough - a preschooler who has asthma and a peak flow meter reading in the green zone - an adolescent who has meningitis and reports a sensitivity to lights and noise
a school-age child who has sickle cell anemia and reports decreased vision in the left eye
a school nurse is assessing an adolescent who has scoliosis which of the following findings should the nurse expect - increase in anterior convexity of the lumbar spine - increased curvature of the thoracic spine - lateral flexion of the neck - a unilateral rib hump
a unilateral rib hump
a nurse in an emergency department is caring for a school age child who is experiencing an anaphylactic reaction which of the following is the priority action by the nurse - elevate the head of the child's bed - insert a large bore IV catheter for a child - determine the allergen that caused the child's reaction - administer epinephrine IM to the child
administer epinephrine IM to the child
a nurse is preparing to administer an immunization to a 4 year old child which of the following actions should the nurse plan to take - place the child in a prone position for the immunization - request that the child's caregiver leave the room during the immunization - administer the immunization using a 24 gauge needled - inject the immunization slowly after aspiration for 3 seconds
administer the immunization using a 24 gauge needled
nurse caring for school age child in Buck's traction following a leg fracture 24 hrs. ago which actions should the nurse take - change the child's position every 2 hr. - clean the peripheral pin sites with chlorhexidine solution ever 4 days - assess peripheral pulses once every 4 hr. - ensure that the head of the bed is elevated to a 90 degree angle
assess peripheral pulses once every 4 hr.
a nurse in an emergency department is caring for toddler who has partial thickness burns on their right arm which of the following actions should the nurse take - insert a nasogastric tube - initiate prophylactic antibiotic therapy - cleanse the affected area with mild soap and water - apply a topical corticosteroid to the affected area.
cleanse the affected area with mild soap and water
nurse assesses a 4 year old child at well-child visit which developmental milestone should the nurse expect to observe - identifies right from left hand - uses a utensil to spread butter - cuts an outlined shape using scissors - drawing a stick figure with seven body parts
cuts an outlined shape using scissors
a school nurse is assessing an adolescent who had multiple burns in various stages of healing which of the following behaviors should the nurse identify as a possible indication of physical abuse - expresses a reluctance to leave home - provides a detailed description of how the burns occurred - denies discomfort during assessment of injuries - describes strong relationship with peers
denies discomfort during assessment of injuries
a nurse is caring for a school-age child who is receiving cefazolin via intermittent IV bolus the child suddenly develops diffuse flushing of the skin and angioedema after discontinuing the medication infusion, which of the following medications should the nurse administer first - prednisone - epinephrine - diphenhydramine - albuterol
epinephrine
a nurse is caring for a school-age child who is receiving a blood transfusion which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction - laryngeal edema - flank pain - distended neck veins - muscular weakness
flank pain
a nurse in an emergency department is caring for a school-age child who has appendicitis and rates their pain as 7 on a 0-10 scale which of the following actions should the nurse take - instill a 500ml tap water enema - give morphine 0.05mg/kg IV - administer polyethylene glycol 1g/kg PO - apply a heating pad to the child's abdomen
give morphine 0.05mg/kg IV
a nurse is teaching the parent of an infant about ways to prevent sudden infant death syndrome (SIDS) which of the following instructions should the nurse include - place the infant in a prone position to sleep - allow the infant to sleep on a large pillow - use a soft mattress in the infant's crib - give the infant a pacifier at bedtime
give the infant a pacifier at bedtime
a nurse is caring for an infant who has respiratory syncytial virus (RSV) which of the following actions should the nurse implement for a infection control - have a designated stethoscope in the infant's room. - place the infant in a room equipped with negative airflow. - administer palivizumab as prescribed for the infant. - remove gloves after leaving the infant's room.
have a designated stethoscope in the infant's room.
a nurse is reviewing the laboratory report of a school-age child who is experiencing fatigue which of the following findings should the nurse recognize as an indication of anemia - hematocrit 28% - hemoglobin 13.5 g/dl - wbc count 8,000/mm3 - platelets 250,000/mm3
hematocrit 28%
a nurse is reviewing the laboratory report of a 7-year-old child who is receiving chemotherapy which of the following laboratory values should the nurse report to the provider - hgb 8.5 g/dl - wbc count 9,500/mm3 - prealbumin 18 mg/dl - platelets 300,000/mm3
hgb 8.5 g/dl
nurse teaches the guardian of 6 month/old infant about care seat use. Which statements by guardian indicates understanding of teaching - i should secure the car seat using lower anchors and tethers instead of the seat belt - i should position the car seat harness 1 inch above my baby's shoulders - i will make sure that the car seat is placed at a 90-degree angle - iwill pad my baby's car seat with a blanket for traveling long distances."
i should secure the car seat using lower anchors and tethers instead of the seat belt
a nurse is teaching a school age child who has a new diagnosis of type 1 diabetes mellitus which of the following statements by the child indicates an understanding of the teaching - i will puncture the pad of my finger when I am testing my blood glucose - i will give myself a shot of regular insulin 30 minutes before I eat breakfast - i will eat a snack of 5 grams of carbohydrates if my blood glucose is low - i will decrease the amount of fluids I drink when I am sick
i will give myself a shot of regular insulin 30 minutes before I eat breakfast
nurse is creating a plan of care for school age child with heart disease and has developed heart failure which of the following interventions should the nurse include in plan - provide small, frequent meals for the child - schedule time in the play room for the child - weigh the child weekly - maintain the child in a supine position
provide small, frequent meals for the child
a nurse is assessing a 3 y/o toddler at a well-child visit which manifestations should the nurse report to the provider - bp 90/50 - rr 45/min - weight 14.5 (32 lbs) - hr 110/min
rr 45/min
a nurse is planning care for a toddler who has a serum lead level of 4 mcg/dl which of the following actions should the nurse plan to take - instruct the parents to decrease the calcium in their toddlers diet - prepare the toddler for chelation therapy - refer the family to child protective services - schedule the toddler for a yearly rescreening
schedule the toddler for a yearly rescreening
nurse is caring for school age child receiving chemotherapy and severely immunocompromised which actions should the nurse take - use surgical asepsis when providing routine care for the child - administer the measles, mumps, and rubella (MMR) vaccine to the child - screen the child's visitors for indications of infection - infuse packed RBCs.
screen the child's visitors for indications of infection
nurse cares for adolescent who received kidney transplant which findings should the nurse ID as indication adolescent is rejecting the kidney - negative leukocyte esterase - serum creatinine 3.0 mg/dL - negative urine protein - urine output 40 mL/hr
serum creatinine 3.0 mg/dL
a nurse is providing teaching to the parent of a school age child who has a new prescription for oral nystatin for the treatment of oral candidiasis which of the following instructions should the nurse include - shake the medication prior to administration - provide the medication through a straw - rinse the child's mouth with water immediately after giving the medication - mix the medication with applesauce if the child dislikes the taste
shake the medication prior to administration
n nurse is reviewing the lab report of an infant who is receiving treatment for severe dehydration the nurse should identify that which of the following laboratory values indicated effectiveness of the current treatment - potassium 2.9 meq/l - sodium 140 meq/l - urine specific gravity 1.035 - bunn 25 mg/dl
sodium 140 meq/l
a nurse is providing discharge teaching to the parent of a child who is 1 week postop following a cleft palate repair for which of the following members of the interprofessional team should the nurse initiate a referral - occupational therapist - speech therapist - respiratory therapist - physical therapist
speech therapist
a nurse in an emergency department is performing a physical assessment on a 2 week old male newborn which of the following findings is priority for the nurse to report to the provider - excoriated scrotal area - multiple capillary hemangiomas - depressed posterior fontanel - substernal retractions
substernal retractions
a charge nurse in an emergency department is preparing an inservice for a group of newly licensed nurses about the manifestations of child maltreatment. which manifestations should the charge nurse include as potential indications of physical abuse - recurrent urinary tract infections - symmetric burns of the lower extremities - failure to thrive - lack of subcutaneous fat
symmetric burns of the lower extremities
a nurse is auscultating the lungs of an adolescent who has asthma the nurse should identify the sound as which of the following - biot respiration - cheyne-strokes respirations - tachypnea - bradypnea
tachypnea
nurse assessing toddler with gastroenteritis and exhibits manifestations of dehydration which findings is the nurse's priority - skin breakdown - hypotension - hyperpyrexia - tachypnea
tachypnea
a nurse is caring for a preschooler who is scheduled for hydrotherapy treatment for wound debridement following a burn injury which of the following actions should the nurse take prior to the procedure - blood pressure 130/90 mm hg - heart rate 60/min - temperature 39.1 C (102.4 F) - urinary output 100 ml/hr
temperature 39.1 C (102.4 F)
nurse interviews parent of 18 month old toddler during well-child visit nurse should ID which findings that indicates a need to assess toddler for hearing loss - toddler has vocabulary of 25 words - the toddler developed a mild rash following a recent varicella immunization - the toddler's moro reflex is absent - the toddler received tobramycin during a hospitalization 2 weeks ago
the toddler received tobramycin during a hospitalization 2 weeks ago
a nurse is teaching the parent of an infant who has Pavlik harness for the treatment of developmental dysplasia of the hip the nurse should identify that which of the following statements by the parent indicates an understanding of the teaching - i should remove the harness at night to allow my infant to stretch her legs - i will need to adjust the straps on the harness once each week - i should apply baby powder to my infant's skin twice daily - i will place my infant's diapers under the harness straps
i will place my infant's diapers under the harness straps
a nurse is creating a plan of care for an infant who has an epidural hematoma from and head injury which of the following interventions should the nurse include in the plan - position the infant side-laying with their head at 0-5 degree angle - perform a neurological assessment every 4 hours - suction the infants nares to remove secretions - implement seizure precautions for the infant
implement seizure precautions for the infant
a nurse is reviewing the lumbar puncture results of a school-age child who is suspected of having bacterial meningitis which of the following findings should the nurse identify as an indication of bacterial meningitis - decreased cerebrospinal fluid pressure - decreased WBC count - increased protein concentration - increased glucose level
increased protein concentration
a nurse is admitting a school-age child who has pertussis which of the following actions should the nurse take - place the child in a room with positive-pressure airflow. - place the child in a room with negative-pressure airflow. - initiate contact precautions for the child. - initiate droplet precautions for the child.
initiate droplet precautions for the child.
a nurse is planning care for school age child who is in oliguric phase of AKI and has sodium level 129 meq/l which of the following interventions should the nurse include in plan - administer ibuprofen to the child for a temperature greater than 38C (100.4 F) - assess the child's blood pressure every 8 hr. - weigh the child weekly at various times of the day - initiate seizure precautions for the child
initiate seizure precautions for the child
a hospice nurse is caring for preschooler with terminal illness one parent of patient tells the nurse that they cannot cope anymore and are thinking about moving out of the house which of the following statements should the nurse make - it is important that you provide emotional support for your family at this time - you have to do what you feel is best everything will turn out fine - i know how you fee this is an extremely stressful time for your family - let's talk about some of the ways you have handled previous stressors in your life
let's talk about some of the ways you have handled previous stressors in your life
a nurse is caring for a toddler who is experiencing acute diarrhea and has moderate dehydration which of the following nutritional items should the nurse offer to the toddler - apple juice - peanut butter - chicken broth - oral rehydration solution
oral rehydration solution
nurse is preparing to collect sample from toddler for sickle-turbidity test. Which actions should the nurse plan to take - obtain a sputum specimen - perform an Allen test - perform a finger stick - obtain a stool specimen
perform a finger stick
a nurse is assessing a school age child with meningitis which of the following findings is the priority for the nurse to report to the provider - reports a headache as 6 on a 0 to 10 pain scale - petechiae on the lower extremities - nuchal rigidity - positive kernig's sign
petechiae on the lower extremities
a nurse is caring for a school age child who has experienced a tonic-clonic seizure which of the following actions should the nurse take during the immediate postictal period - place the child in a side-lying position - delay documentation until the child is fully alert. - give the child a high-carbohydrate snack - administer an oral sedative to the child
place the child in a side-lying position
a nurse is providing teaching about play activities for social development to the parents of a preschooler which of the following play activities should the nurse recommend for the child - playing pat-a-cake - using a push-pull toy - creating a scrapbook - playing dress-up
playing dress-up
nurse provides dietary teaching to parent of school age child with celiac disease nurse should recommend parent offer which foods to child - wheat crackers - rye bread - barley soup - white rice
white rice
a nurse in a provider's office is preparing to administer immunizations to toddler during a well-child visit which actions should the nurse plan to take (tuberculin skin test (TST), measles, mumps, and rubella (MMR) vaccine, Inactivated influenza vaccine, diphtheria, tetanus, and pertussis (DTaP) vaccine, rr 24/min, hr 115/min, temp 36.9 C (98.4 F), age 15 months, height 71.1 cm (28 in), allergies neomycin (anaphylactic reaction), caregiver reports rhinitis with clear nasal drainage for 2 days, occasional nonproductive cough for 2 days, history of asthma) - withhold the measles, mumps, and rubella (MMR) vaccine - withhold the diphtheria, tetanus, and pertussis (DTaP) vaccine - withhold the influenza vaccine - withhold the tuberculin skin test (TST).
withhold the measles, mumps, and rubella (MMR) vaccine
a nurse is caring for a 15 year old client who is married and is scheduled for a surgical procedure the client asks who should sign my surgical consent which of the following responses should the nurse make - you can sign the consent form because you are married - your spouse should sign the consent form for you - your parent should sign the consent form for you - you can appoint a legal guardian to sign the consent form
you can sign the consent form because you are married
a nurse is caring for a preschooler whose father is going home for a few hours while another relative stays with the child which of the following statements should the nurse make to explain to the child when their father will return - your daddy will back at 7pm - our daddy will be back after he takes care of your brother - your daddy will be back in the morning - your daddy will be back after you eat
your daddy will be back after you eat
a nurse is providing teaching to the parent of an infant who has diaper dermatitis the nurse should instruct parent to apply what to the affected areas - zinc oxide - antibiotic ointment - talcum powder - antiseptic solution
zinc oxide
