ATI RN
ATI Nursing Care of Children 2019 B
1. A child with pyloric stenosis is having excessive vomiting. The nurse should assess for what potential complication?
- A. Hyperkalemia
- B. Hyperchloremia
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct answer: D
Rationale: Excessive vomiting in pyloric stenosis leads to the loss of stomach acid (hydrochloric acid), resulting in metabolic alkalosis, not hyperkalemia, hyperchloremia, or metabolic acidosis. Metabolic alkalosis is characterized by a higher pH level in the blood due to the loss of acid and a relative increase in bicarbonate. Hyperkalemia is an elevated level of potassium in the blood and is not directly related to excessive vomiting in pyloric stenosis. Hyperchloremia is an excess of chloride in the blood, which is not typically associated with this condition. Metabolic acidosis is a condition characterized by a lower pH level in the blood, caused by an excess of acid or a loss of bicarbonate, which is not the typical complication seen in pyloric stenosis with excessive vomiting.
2. .A nurse assesses a clients peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next?
- A. Apply cold compresses to the IV site.
- B. Elevate the extremity on a pillow.
- C. Flush the catheter with normal saline.
- D. . Stop the infusion of intravenous fluids.
Correct answer: . Stop the infusion of intravenous fluids.
Rationale:
3. The client states, “Why am I getting protein supplements while I am healing from a bed sore?” What is the best response by the nurse?
- A. ‘Because it is easy to digest.’
- B. ‘Protein has amin acid that promotes wound healing.’
- C. ‘If you do not like it, you do not have to take it.’
- D. ‘These supplements have nothing to do with your wound,’
Correct answer: ‘Protein has amin acid that promotes wound healing.’
Rationale:
4. Which regulatory body mandates the provision of immunizations, especially for hepatitis B?
- A. American Nurses Association (ANA)
- B. Occupational Safety and Health Administration (OSHA)
- C. Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
- D. State board of nursing
Correct answer: B
Rationale: The correct answer is B - Occupational Safety and Health Administration (OSHA). OSHA mandates that the hepatitis B vaccine series must be offered to healthcare workers who are not immune to hepatitis. This requirement aims to protect healthcare workers from occupational exposure to bloodborne pathogens, including the hepatitis B virus. The American Nurses Association (ANA) (Choice A) is a professional organization for nurses, not a regulatory body. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (Choice C) focuses on accrediting healthcare organizations for quality and safety, not mandating immunizations. The State board of nursing (Choice D) is responsible for regulating nursing practice within a specific state, not mandating immunizations.
5. A healthcare professional is preparing to administer a blood transfusion to a client. Which of the following actions should the healthcare professional take first?
- A. Obtain the client's vital signs.
- B. Ensure the client's IV access is patent.
- C. Prime the IV tubing with 0.9% sodium chloride.
- D. Verify the client's identity.
Correct answer: D
Rationale: Verifying the client's identity is the first crucial action the healthcare professional should take before administering a blood transfusion. This step ensures that the right blood is given to the right client, helping prevent errors. Obtaining vital signs, ensuring IV access, and priming IV tubing are important steps in the process but verifying the client's identity takes precedence for patient safety and accurate care delivery.
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