ATI RN
RN Nursing Care of Children 2019 With NGN
1. A child with acute glomerulonephritis is in the playroom and experiences blurred vision and a headache. What action should the nurse take?
- A. Check the urine to see if hematuria has increased.
- B. Obtain the child's blood pressure and notify the healthcare provider.
- C. Obtain serum electrolytes and send urinalysis to the laboratory.
- D. Reassure the child and encourage bed rest until the headache improves.
Correct answer: B
Rationale: Blurred vision and headache in a child with acute glomerulonephritis may indicate severe hypertension, which requires immediate assessment and intervention. Blood pressure should be checked, and the healthcare provider notified.
2. A healthcare provider is caring for a client who has a new prescription for Clonidine. Which of the following adverse effects should the healthcare provider monitor?
- A. Drowsiness
- B. Dry mouth
- C. Weight gain
- D. Insomnia
Correct answer: B
Rationale: The correct answer is B: Dry mouth. Dry mouth is a common adverse effect of Clonidine. Clonidine can cause a reduction in salivary flow, leading to dry mouth. This symptom can be managed by increasing fluid intake or using sugar-free gum or candy to stimulate saliva production. Choices A, C, and D are incorrect. While drowsiness and insomnia are potential side effects of Clonidine, dry mouth is more commonly reported. Weight gain is not typically associated with Clonidine use.
3. What evaluation indicates successful progress on the client goal of increasing daily physical activity?
- A. The client reports decreased social interaction
- B. The client reports more nonsteroidal anti-inflammatory drug (NSAID) use
- C. The client reports a fall
- D. The client reports less fatigue walking up stairs
Correct answer: D
Rationale: The correct answer is D because reporting less fatigue when walking up stairs indicates improved physical endurance, showing progress in increasing daily activity. Choices A, B, and C are incorrect because decreased social interaction, increased NSAID use, and experiencing a fall are not indicators of successful progress in increasing daily physical activity.
4. The nurse is caring for a patient in the hospital. The nurse observes the nursing assistive personnel (NAP) turning off the handle faucet with bare hands. Which professional practice principle supports the need for follow-up with the NAP?
- A. The nurse is responsible for providing a safe environment for the patient.
- B. This step is crucial in the process of handwashing.
- C. Different scopes of practice allow for procedure modifications.
- D. Leaving the water running wastes resources and money.
Correct answer: A
Rationale: The correct answer is A. The nurse is responsible for providing a safe environment for the patient. In this situation, the nurse should follow up with the nursing assistive personnel (NAP) who turned off the handle faucet with bare hands to ensure infection control practices are maintained. This action is crucial to prevent the spread of infections in the hospital setting. Choice B is incorrect because the question is not specifically about handwashing procedures but about infection control practices. Choice C is incorrect as it does not address the potential risk of infection transmission. Choice D is incorrect as it is unrelated to the main concern of infection control in this scenario.
5. A nurse is caring for a client who has dehydration. The client has a peripheral IV and a prescription for an infusion of 0.9% sodium chloride 1,000 mL with 40 mEq potassium chloride to infuse over 1 hr. Which of the following actions should the nurse take first?
- A. Teach the client to report findings of IV extravasation
- B. Evaluate the patency of the IV
- C. Consult with the pharmacist about the prescription
- D. Verify the prescription with the provider
Correct answer: D
Rationale: The nurse's priority action should be to verify the prescription with the provider. This is crucial to prevent injury from fluid volume overload and rapid potassium infusion. Verifying the prescription ensures that the correct solution, rate, and additives are ordered according to the client's condition. While evaluating the patency of the IV is important, verifying the prescription takes precedence to ensure patient safety. Consulting with the pharmacist can be beneficial, but confirming the prescription with the provider is the immediate priority. Teaching the client about IV extravasation is important but is not the first action the nurse should take in this scenario.
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