ATI RN
ATI Nursing Care of Children 2019 B
1. A 6-month-old infant with Hirschsprung disease is scheduled for a temporary colostomy. What should postoperative teaching to the parents include?
- A. Dilating the stoma
- B. Assessing bowel function
- C. Limitation of physical activities
- D. Measures to prevent prolapse of the rectum
Correct answer: B
Rationale: Postoperative teaching should focus on assessing bowel function to ensure the colostomy is functioning properly. This includes monitoring stool output, color, consistency, and signs of infection or blockage. Choice A, dilating the stoma, is not recommended without healthcare provider guidance, as it can lead to complications. Choice C, limitation of physical activities, may not be as crucial immediately after colostomy creation. Choice D, measures to prevent prolapse of the rectum, is more relevant for conditions like rectal prolapse and not specifically for a colostomy.
2. When caring for a client with a new prescription for enoxaparin for the prevention of DVT, what is an appropriate action by the nurse?
- A. Expel any air bubbles at the top of the prefilled syringe
- B. Massage the injection site to evenly distribute the medication
- C. Inject the medication into the lateral abdominal wall
- D. Administer an NSAID for injection site discomfort
Correct answer: C
Rationale: When administering enoxaparin for the prevention of DVT, the nurse should inject the medication into the lateral abdominal wall. This site is preferred for subcutaneous injections of enoxaparin to reduce the risk of bleeding or injury. Expelling air bubbles, massaging the injection site, or administering an NSAID for discomfort are not appropriate actions and could lead to complications or ineffective medication delivery.
3. A nurse is caring for a client who is receiving warfarin therapy. Which of the following laboratory results indicates the need for an increase in the dose of warfarin?
- A. PT 28 seconds
- B. INR 1.2
- C. aPTT 40 seconds
- D. Fibrinogen 350 mg/dL
Correct answer: B
Rationale: An INR of 1.2 is below the therapeutic range for a client on warfarin, indicating inadequate anticoagulation. Therefore, the client would require an increase in the dose of warfarin to achieve the desired therapeutic effect. Choices A, C, and D are not indicative of the need for a dose increase in warfarin therapy. PT of 28 seconds is within the therapeutic range, aPTT of 40 seconds is also within the normal range, and fibrinogen level of 350 mg/dL does not provide information about the anticoagulant effect of warfarin.
4. After a violent incident, staff needs to discuss what occurred. Several actions need to be taken following the incident:
- A. Debrief the staff and complete incident reports and verify that all staff are safe
- B. Reassure the violent patient that hurting staff when ill is not cause for concern
- C. Avoid any interactions
- D. Standing close to the patient while talking
Correct answer: A
Rationale: Corrected Rationale: After a violent incident, it is crucial to debrief the staff and complete incident reports to document what occurred and ensure proper follow-up actions. Verifying that all staff are safe is essential for their well-being and security. This process allows professionals to assess the situation, learn from it, and be better prepared to handle similar incidents in the future. Choice B is incorrect because reassuring a violent patient that hurting staff is not a cause for concern may diminish the seriousness of the incident. Choice C is incorrect as avoiding interactions does not address the need for proper communication and resolution. Choice D is incorrect as standing close to a patient who has been violent may escalate the situation and compromise safety.
5. A nurse is caring for a patient who is being treated with clomiphene citrate (Clomid) for infertility. What side effect should the nurse warn the patient about?
- A. Headaches and visual disturbances
- B. Nausea and vomiting
- C. Hot flashes and abdominal discomfort
- D. Fatigue and depression
Correct answer: C
Rationale: The correct answer is C: 'Hot flashes and abdominal discomfort.' Clomiphene citrate, commonly known as Clomid, can lead to hot flashes and abdominal discomfort as side effects. It is important for the nurse to warn the patient about these potential effects. Choices A, B, and D are incorrect because headaches and visual disturbances, nausea and vomiting, as well as fatigue and depression are not commonly associated with clomiphene citrate use.
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