ATI RN
RN Pediatric Nursing 2023 ATI
1. 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?
- A. Elevate the head of the child's bed
- B. Insert a large-bore IV catheter for the child
- C. Determine the allergen that caused the child's reaction
- D. Administer IM epinephrine to the child
Correct answer: D
Rationale: In the management of anaphylaxis, the priority action for the nurse is to administer IM epinephrine to the child. Epinephrine is the first-line treatment for anaphylaxis as it helps reverse the severe manifestations of the reaction by constricting blood vessels, relaxing airway muscles, and decreasing hives and swelling. Elevating the head of the child's bed may be beneficial for respiratory distress but is not the priority over administering epinephrine. Inserting a large-bore IV catheter may be necessary for fluid resuscitation but is not the initial priority. Identifying the allergen is important for prevention and future management but is not the immediate action needed in the acute phase of an anaphylactic reaction.
2. During an assessment, a healthcare professional is evaluating an infant with pneumonia. Which of the following findings should be the priority for the healthcare professional to report to the provider?
- A. Nasal flaring
- B. WBC count of 11,300
- C. Diarrhea
- D. Abdominal distension
Correct answer: A
Rationale: When assessing an infant with pneumonia, the priority finding to report to the provider is nasal flaring. Nasal flaring indicates acute respiratory distress, which can be a life-threatening condition requiring immediate intervention. Monitoring and addressing respiratory distress take precedence over other symptoms or laboratory results in this situation.
3. During a well-child visit, a nurse is assessing a three-year-old toddler. Which of the following manifestations should the nurse report to the provider?
- A. Blood pressure 90/50
- B. Respiratory rate 45/min
- C. Weight 14.5 kg or 32 lb
- D. Heart rate 110/min
Correct answer: B
Rationale: A respiratory rate of 45/min is above the expected reference range for a 3-year-old toddler and may indicate respiratory dysfunction or acute respiratory distress. It is essential for the nurse to report this finding promptly to the healthcare provider for further evaluation and intervention.
4. A healthcare professional is performing hearing screenings for children at a community health fair. Which of the following children should the professional refer to a provider for a more extensive hearing evaluation?
- A. A toddler who is 18 months old and has unintelligible speech
- B. An infant who is 3 months old and has an exaggerated startle response
- C. A preschooler who is 4 years old and prefers playing with others rather than alone
- D. An infant who is 8 months old and is not yet making babbling sounds
Correct answer: D
Rationale: The healthcare professional should refer an infant who is not making babbling sounds by the age of 7 months to a provider for a more extensive evaluation of hearing. Babbling sounds are a developmental milestone that typically occurs by 7 months of age. Delayed or absent babbling can indicate potential hearing issues that warrant further assessment.
5. When providing teaching to the family of a school-age child with juvenile idiopathic arthritis, which instruction should the nurse include?
- A. Limit the child's movement of the large joints.
- B. Encourage the child to perform independent self-care.
- C. Provide the child with a soft mattress for sleeping.
- D. Schedule a 2-hour daily nap for the child in the afternoon.
Correct answer: B
Rationale: Encouraging the child to perform independent self-care is essential when managing juvenile idiopathic arthritis. This instruction helps minimize pain and stiffness in the child's joints while promoting mobility and independence. It is crucial for the child to learn self-management skills early to cope better with the condition in the long term.
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