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 priorit
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Nursing Elites

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?

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. A child is being cared for following a head injury. Which of the following findings should indicate to the healthcare provider that the child is developing diabetes insipidus?

Correct answer: B

Rationale: In a child with a head injury, the development of diabetes insipidus can occur due to pituitary hypofunction, leading to a deficiency of antidiuretic hormone. An elevated sodium level (hypernatremia) is a key finding in diabetes insipidus due to the excessive loss of free water in the urine, resulting in increased sodium concentration in the blood.

3. Before administering a live virus vaccine to a patient taking a glucocorticoid medication, what action should the nurse take?

Correct answer: C

Rationale: The correct action for the nurse to take when a patient on glucocorticoid medication is to note the contraindication and clarify the order with the healthcare provider. Glucocorticoids can suppress the immune response, potentially reducing the effectiveness of vaccines. Therefore, it is crucial to consult with the healthcare provider to assess the risks and benefits of administering a live virus vaccine in such circumstances. Administering a live virus vaccine to a patient taking glucocorticoids can increase the risk of developing a viral infection, making it essential to seek guidance from the healthcare provider before proceeding.

4. A parent of an infant with diaper dermatitis is being taught by a nurse. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The nurse should instruct the parent to expose the infant's skin to air as it helps in promoting the healing process of diaper dermatitis by allowing the skin to breathe and reducing moisture, which can worsen the condition.

5. A young child admitted to the pediatric unit has fever, irritability, and vomiting with suspected bacterial meningitis. Which cerebrospinal fluid (CSF) result should the nurse anticipate based on these data?

Correct answer: D

Rationale: In bacterial meningitis, the glucose level in the cerebrospinal fluid (CSF) is typically decreased due to the increased utilization of glucose by the infecting bacteria. This metabolic change leads to a decrease in CSF glucose levels, making choice D the correct answer in this scenario. Choices A, B, and C are incorrect because bacterial meningitis usually results in an increased protein count, cloudy appearance of the CSF due to the presence of bacteria, and absence of red blood cells (RBCs) in the CSF unless there is a traumatic tap, respectively.

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