ATI Test A.
A nurse is reinforcing teaching about home safety with the parent of a toddler. Which of the
following parent statements indicates an understanding of the teaching?
- The nurse should instruct the parent t
...
ATI Test A.
A nurse is reinforcing teaching about home safety with the parent of a toddler. Which of the
following parent statements indicates an understanding of the teaching?
- The nurse should instruct the parent to place a screen in front of a fireplace or other
heating appliances to prevent burns
A nurse is reinforcing teaching with the parent of a child who has hemophilia and is
experiencing acute hemarthosis. Which of the following instructions should the nurse include in
the teaching?
- The nurse should reinforce with the parent to keep the child’s affected joints elevated
and immobilized to minimize bleeding. After the acute episode, the child should begin
active range-of-motion exercise.
A nurse is collecting data about the dietary habits of an adolescent client. The nurse should
identify that which of the following findings puts the client at risk for nutritional deficits?
- The nurse should identify that adolescents are often at risk for developing poor eating
habits. Skipping dinner twice each week puts this client at risk for nutritional deficits.
A nurse is assisting with the care of a child who has tonic-clonic seizures. Which of the following
actions should the nurse take?
- The nurse should have a suction canister and tubing available in the child’s room to keep
the child’s airway patent during a seizure.
A nurse is reinforcing home safety instructions with the parents of a toddler. Which of the
following parent statements indicates an understanding of the teaching?
- The nurse should instruct the parents to turn pot handles toward the back of the stove
to prevent the toddler from pulling a pot off the stove, resulting in a burn.
A nurse in a pediatric clinic is collecting data from an infant who recently started taking digoxin.
Which of the following manifestations should the nurse identify as an indication of digoxin
toxicity and report to the provider?
- The nurse should identify that vomiting, especially unrelated to feedings, is a
manifestation of digoxin toxicity and should be reported to the provider.
A nurse is caring for a school-age girl who is being treated for frequent, severe urinary tract
infections (UTIs). The nurse should recognize that which of the following statements by the
parent indicates a possible cause of the UTIs?
- My daughter has bowel movements every 4 to 5 days—the nurse should recognize that
this frequency indicates the child is constipated. Therefore, large stool masses might
prevent complete emptying of the bladder and lead to urinary stasis and infection.
A nurse is caring for a school-age child who has been admitted to facility in sickle cell crisis.
The nurse is measuring the child’s oral intake for the shift. The child consumed 4 oz of juice at
breakfast. For lunch, the child consumed 6 oz of milk, 6 oz of gelatin, and drank 7 oz of water.
What is the child’s oral intake for this shit of milliliters. (Round to the nearest whole number.)
- 1oz = 30 mL
Client consumed 23 oz of fluids
23 oz X 30 mL = 690 mL
A nurse is reinforcing dietary teaching with the guardian of a school age child who has celiac
disease. Which of the following foods should the nurse recommend including in the child’s diet?
- White rice—the nurse should reinforce to the guardian that celiac disease is a genetic
autoimmune disorder in which eating gluten, even in a very small amounts, can damage
the child’s small intestine. Currently, the only treatment for the disease is a lifelong,
stick adherence to a gluten-free diet. The nurse should stress the importance of
avoiding foods containing wheat, rye, barley, and oats. The child should consume foods
that are gluten-free, such as milk, cheese, rise, corn, eggs, potatoes, fruits, vegetables,
fresh poultry, meats, fish and dried beans.
A nurse is reviewing the laboratory report of a preschooler. Which of the following laboratory
results should the nurse report to the provider?
- Lead 14 mcg/dL—the lead level is above the expected reference range for a
preschooler. Therefore, the nurse should report this result to the provider.
A nurse is reviewing the medical record of a female adolescent client who has primary
amenorrhea. Which of the following findings should the nurse identify as a risk factor for this
disorder?
- Hypothyroidism
- Cannabis
- Oral contraceptive
- Emotional stress
A nurse is reinforcing teaching with the guardian of child who has scabies and a new
prescription for permethrin 5% cream. Which of the following information should the nurse
include?
- The medication will eliminate your child’s itching within 2 to 3 weeks—the nurse should
instruct the guardian that, although the medication kills the mites, itching can continue
for 2 to 3 weeks following application of the medication.
A nurse is preparing to administer ophthalmic drops to a child. Which of the following actions
should the nurse take?
- Apply pressure to the lacrimal punctum for 1 min following administration—the nurse
should apply pressure to the lacrimal punctum to prevent the medication from entering
the nasopharynx.
A nurse is reinforcing discharge teaching with the parent of a school-age child who is being
treated from nephrotic syndrome. The parent asks the nurse why it is necessary to check the
child’s urine for protein. Which of the following explanations should the nurse offer?
- A decrease in urine protein indicates that treatment is effective—the desired outcome
of steroid therapy in the treatment of nephrotic syndrome is a reduction of proteinuria.
A nurse is assisting the provider with a developmental assessment of a toddler. Which of the
following behaviors should the nurse recognize as an expected finding?
- Standing of one foot for several seconds is an expected behavior for a toddler.
A nurse is collecting data from an infant who has severe dehydration. Which of the following
findings should the nurse expect?
- The nurse should expect an infant who has severe dehydration to experience weight
loss of 10% or greater.
A nurse is caring for an adolescent client who is practicing Jehovah’s Witness and is scheduled
for surgery for a ruptured appendix. The adolescent tells the nurse that based on her religious
beliefs, she cannot receive a blood transfusion. Which of the following responses should the
nurse make?
- Let’s discuss the possibility of you needing a blood transfusion with your parents—the
nurse should offer to involve the child’s parents to understand the family’s beliefs about
blood transfusions.
A nurse is auscultating heart sounds on an infant. The nurse should identify this sound as which
of the following?
- Sinus rhythm—the nurse should auscultate heart sounds at the apical impulse, which is
at the left midclavicular line and fifth intercoastal space. The expected heart sounds
include S1, which is the closure of the atrioventricular valves, and S2, which is the
closure of the semilunar valves.
A nurse is reinforcing teaching with the family of a preschooler whose parent has a terminal
diagnosis. Which of the following statements should the nurse include when discussing ageappropriate response to death?
- At this age, your child likely believes his thoughts can cause another person’s death—
which can make him feel guilty or responsible for the death
A nurse in a community center is reinforcing teaching about poison control with a group of
parents. A parent asks what to do if a child ingests a large quantity of acetaminophen. Identify
the sequence of actions the nurse should recommend to the parent.
- Determine if the child is breathing
- Empty the child’s mouth of remaining pills and residue
- Identify the medication and dosage strength
- Call a poison control center
A nurse is collecting data from a toddler at a well-child visit. Which of the following findings
should the nurse identify as a possible indication of child maltreatment?
- A laceration on the side of the torso is not an injury that occurs due to the typical
clumsiness of a toddler. This finding indicates the need to further investigate for
suspected child maltreatment.
A nurse is assisting with a sterile dressing change for an adolescent who has a partial thickness
burn on the right hip. Which of the following actions should the nurse take first?
- Administer pain medication to the client—reduce discomfort during the procedure
A nurse is reinforcing teaching with the parents of a 7-year-old female child about behavioral
expectations. Which of the following behaviors should the nurse include in the teaching?
- Spending time alone is an expected characteristic of a 7-year-old female child. When
they do spend time with others, children in this age group prefer to socialize with
children of the same sex and age.
A nurse is assisting with the care of a 3-year-old child who is prescribed a lumbar puncture.
Which of the following actions should the nurse take to prevent complications?
- Maintain the child in a flat position after the procedure—to prevent headaches
A nurse is reinforcing teaching with the parents of a child who has cystic fibrosis and is taking
pancrelipase as a pancreatic enzyme replacement. The nurse should plan to inform the child’s
parents that the therapeutic effects of this medication can be evaluated by which of the
following?
- Amount and consistency of stools—will help determine the effectiveness of
pancrelipase, which is taken to decrease the bulk of feces
A nurse in a pediatric clinic is collecting data from an infant who was recently exposed to
pertussis. The nurse should recognize which of the following as a manifestation of pertussis?
- Dry cough—early manifestation of pertussis
A nurse is reinforcing teaching with the guardians of a school-age child who has hearing loss.
Which of the following techniques should the nurse recommend to facilitate communication
with the child?
- Speak at the child’s eye level—and ensure that there is adequate lighting on the
speaker’s face to facilitate lipreading and communication
A nurse is reinforcing teaching about injury prevention with the guardian of an infant. Which of
the following statements by the guardian indicates an understanding of the teaching?
- I should make sure my baby’s clothing does not have buttons on it—reduce the risk of
choking and aspiration
A nurse is collecting data from a 12-month-old infant during a well-child visit. The nurse should
identify which of the following findings as a deviation from expected growth and development?
- Birth weight doubled
A nurse is reviewing the laboratory report of a school-age child who is receiving prednisone.
Which of the following laboratory results should the nurse report to the provider?
- Sodium 150 mEq/L—hypernatremia is an adverse effect of prednisone. This level is
above the expected reference for a school aged child.
A nurse is assisting with the care of an infant who has spina bifida and recently has a
ventriculoperitoneal shunt placed for hydrocephalus. Which of the following findings should the
nurse identify as an indication of increased intracranial pressure?
- High pitched cry—indication of increased intracranial pressure
A nurse is assisting with the administration of a nasogastric enteral feeding for an infant. Which
of the following actions should the nurse take?
- Place the infant in semi-fowler’s position for 1 hr after the feeding—elevate the head of
the infant’s bed by 30 to 45 degrees for 30 min to 1 hr after the feeding.
A nurse is reinforcing discharge teaching with the guardian of a child who has juvenile
idiopathic arthritis (JIA). Which of the following statements by the parent indicates an
understanding of the teaching?
- I will have my child sleep in knee, wrist and hand splints—splinting the child’s joints at
night will decrease pain and enhance joint function
A nurse is preparing to administer an enteral feeding to a child who has cerebral palsy and a
nasogastric tube. Which of the following action should the nurse take?
- Confirm that the pH of the stomach contents is 5 or less—prior to administering the
tube feeding in order to confirm tube placement in the stomach
A nurse is monitoring a preschooler following an abdominal CT scan with contrast dye. The
nurse should identify which of the following as an indication that the preschooler experienced
an allergic reaction to the contrast dye?
- Urticaria—manifestations of the allergic reaction include urticaria, itching, flushing of
the skin, and possible anaphylaxis
A nurse is reinforcing teaching with the guardian of a child who has a new diagnosis of
enterobiasis. The nurse should advise the guardian to take which of the following actions to
prevent infection?
- Trim the child’s fingernails short—reduces the collection of eggs under her nails and
prevent reinfection
A nurse is reinforcing teaching with the parents of a toddler who has strabismus. Which of the
following treatments should the nurse plan to include in the teaching?
- Eye patch—covering the strong eye to strengthen the muscles in the weak eye
A nurse in a pediatric clinic is observing for an anaphylactic reaction after administering an IM
antibiotic to a child 5 min ago. Which of the following manifestations should the nurse expect
to observe first?
- Hives—an early manifestation of an anaphylactic reaction
A nurse is contributing to the plan of care for an adolescent client who has human
immunodeficiency virus (HIV). Based on the adolescent’s diagnosis, which of the following
actions should be included in the plan of care?
- Inform the client regarding routes of transmission
A nurse is collecting data from a child who has iron deficiency anemia. Which of the following
data signifies that adherence to ferrous sulfate therapy has occurred?
- Green, tarry stools
A nurse is reinforcing teaching with an adolescent female client who has acne vulgaris and new
prescription for isotretinoin. Which of the following information should the nurse include?
- You will need to have two negative pregnancy tests prior to starting this medication—
isotretinoin is teratogenic and should use two effective forms of contraception while
taking this medication
A nurse is reinforcing teaching about tracheostomy care with the parent of a toddler who has a
temporary tracheostomy. Which of the following instructions should the nurse include in the
teaching?
- Ensure one finger fits between the ties and the neck—ensure the tube is held securely in
place
A nurse is collecting data from a 6-month-old child who is experiencing a sickle cell crisis. Which
of the following areas should the nurse observe when monitoring for manifestations of splenic
sequestration?
- The nurse should observe the location over the infant’s spleen when monitoring for
manifestations of splenic sequestration. Splenic sequestration is an enlargement of the
spleen due to pooling of sickled cells in the blood.
A nurse is reinforcing discharge teaching with the guardian of a school-age child who has new
prescription for home oxygen therapy. Which of the following statements by the guardian
indicates an understanding of the teaching?
- I will make sure that electrical devices in the house are grounded—due to the
combustible nature of oxygen, all pieces of electrical equipment in the home should be
grounded to decrease the risk of a fire caused by an electrical spark.
A nurse is collecting data from a toddler who has gastroesophageal reflex disease (GERD).
Which of the following findings should the nurse expect?
- Chronic cough
A nurse is caring for a preschooler who has a new diagnosis of asthma. Which of the following
medications should the nurse instruct the parent to administer for an acute asthma attack?
- Albuterol—a short acting beta2 agonist, to the preschooler for acute asthma attacks.
A nurse is reviewing the laboratory report of a preschooler who has a Wilms’ tumor and is
scheduled to begin treatment with an antineoplastic medication regimen. Which of the
following laboratory results should the nurse report to the provider?
- Platelet count 70,000/mm3—below the expected reference range for a preschooler and
increases the risk for spontaneous bleeding.
A nurse is collecting data from a 12 month old infant during a well-child visit. Which of the
following findings should the nurse report to the provider?
- BP 115/70 mm Hg—blood pressure is above the expected reference ranger for a 12
month old infant.
A nurse is contributing to the plan of care for a child who has sickle cell anemia and is
experiencing a vaso-occlusive crisis. Which of the following is the priority intervention for the
nurse to recommend to include in the plan?
- Promote oxygen utilization—use the airway, breathing, circulation (ABC) approach to
client care is promoting oxygen utilization to prevent further sickling of the red blood
cells and promote adequate oxygenation of the tissue
A nurse is preparing to administer the measles, mumps and rubella (MMR) vaccine to a
preschooler. The nurse should recognize which of the following statements by the parent as a
contraindication to receiving the immunization?
- My child received an immunoglobin last month—preschooler who received an
immunoglobin less than 1 month ago should not receive the MMR vaccine on this day.
The nurse should instruct the parent to reschedule the immunization after 3 months
have elapsed, since the child received passive immunity via administration of an
immunoglobin.
A nurse is reinforcing discharge teaching with the guardian of a school-age child who has acute
lymphocytic leukemia and an absolute neutrophil count of 450/mm3. Which of the following
instructions should the nurse include?
- Keep your child away from crowded areas—decrease the risk for infection
A nurse is assisting with scoliosis screenings for a group of school-age children. The nurse
should place the students in which of the following positions during the screening.
- Bending forward with back parallel to the floor—observe for asymmetry and
prominence of the rib cage by having the students bend forward with be back parallel to
the floor.
A nurse has just received change-of-shift report for four children in a pediatric unit. Which of
the following children should the nurse collect data from first?
- A child who has a fever and nuchal rigidity—is unstable; finding bacterial meningitis,
which requires urgent data collection and intervention to reduce complications for the
child and prevent further spread of the infection.
A nurse is collecting data about a 4 year old preschooler’s gross motor skills. The nurse should
expect the preschooler to be able to perform which of the following activities?
- Hopping on one foot
A nurse is reinforcing teaching with the parent of a child who has a new prescription for ferrous
sulfate. The nurse should reinforce that the parent should administer the medication with
which of the following fluids to enhance medication absorption?
- Orange juice—will enhance medication absorption
A nurse is reinforcing teaching about glucose monitoring with the parent of a child who has
type 1 diabetes mellitus. Which of the following instructions should the nurse include in the
teaching?
- Put your child’s finger under warm, running water prior to collecting blood—will make it
easier to obtain the sample
A nurse is reinforcing dietary teaching about a low-sodium diet with the parents of a child who
is recovering from acute glomerulonephritis. Which of the following food choices by the
parents indicates an understanding of the teaching?
- Apples—low in sodium and supply the child with energy needed for recovery
A nurse in a clinic is collecting data from an adolescent who has received all recommended
immunizations through the age of 6 years. Which of the following immunizations should the
nurse plan to administer?
- Tetanus, diphtheria toxoids, and acellular pertussis (Tdap)—recommended between the
ages of 11 and 12 years
A nurse is reinforcing teaching regarding the immunization schedule of a newborn. Which of
the following statements made by the parent should the nurse recognize as an understanding
of the newborn’s immunization schedule?
- My baby will receive his next immunization when he is 2 months old
A nurse is caring for a school-age child who has skeletal traction applied to the right lower leg
to repair a femur fracture. Which of the following findings is the priority for the nurse to
report to the provider?
- Report of tingling in the right foot—greatest risk to the child is nerve injury. Therefore,
tingling in the right foot, which can indicate nerve damage or compartment syndrome.
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