a nurse is caring for a toddler with respiratory syncytial virus rsv which action should the nurse take
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment Form A

1. A nurse is caring for a toddler with respiratory syncytial virus (RSV). Which action should the nurse take?

Correct answer: A

Rationale: Using a designated stethoscope for the toddler is crucial to reduce the risk of spreading RSV to other patients. Choice B is incorrect because N95 respirator masks are not specifically indicated for RSV. Choice C is unnecessary as RSV does not require isolation in a negative pressure room. Choice D is incorrect because the gown should be removed after leaving the room to prevent transmission of pathogens to other areas.

2. A nurse is assessing a client who has meningitis. The nurse should identify which of the following findings as a positive Kernig’s sign?

Correct answer: B

Rationale: A positive Kernig’s sign is identified when a client is unable to extend their leg completely without pain after hip flexion. This finding indicates meningeal irritation. Choices A, C, and D do not describe Kernig’s sign. Choice A describes a normal plantar reflex, choice C refers to coordination issues, and choice D describes neck pain and stiffness, which are not specific to Kernig’s sign.

3. A nurse is teaching postoperative care to the parents of a toddler following a cleft palate repair. Which of the following should be included in the teaching?

Correct answer: D

Rationale: The correct answer is D. Elbow splints are utilized to prevent the child from touching the surgical site. However, it is essential to remove them periodically to conduct range-of-motion exercises to prevent joint stiffness. Choices A, B, and C are incorrect because providing an orthodontic pacifier, offering fluids using a straw, and cleansing the suture line with a cotton-tip swab are not directly related to postoperative care following a cleft palate repair.

4. A healthcare professional is assessing a client for signs of anemia. Which of the following findings should the healthcare professional expect?

Correct answer: B

Rationale: Pale skin is a common sign of anemia due to reduced hemoglobin levels, leading to decreased oxygen delivery to tissues. This results in skin pallor. Choices A, C, and D are incorrect. Anemia typically causes fatigue and decreased energy levels (not increased), low blood pressure (not elevated), and tachycardia (increased heart rate) to compensate for the decreased oxygen-carrying capacity of the blood.

5. A nurse in an outpatient facility is assessing a client who is prescribed furosemide 40 mg daily, but the client reports she has been taking extra doses to promote weight loss. Which of the following indicates she is dehydrated?

Correct answer: B

Rationale: Oliguria (reduced urine output), increased urine concentration, and a urine specific gravity greater than 1.030 are indicative of dehydration, particularly in clients using diuretics excessively. Choice A is incorrect because a urine specific gravity of 1.035 is high, indicating concentrated urine but not specifically dehydration. Choice C, polyuria, refers to increased urine output and is not consistent with dehydration. Choice D, hypotension, is a sign of fluid volume deficit but is not specific to dehydration as described in the scenario.

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