a nurse is planning care for a 2 month old infant who is postoperative following surgical repair of a cleft lip which of the following actions should
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Nursing Elites

ATI RN

ATI Pediatric Proctored Exam 2023

1. A nurse is planning care for a 2-month-old infant who is postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take?

Correct answer: D

Rationale: The nurse should keep the infant’s elbow restrained to prevent injury to the surgical site.

2. Which statement is not a principle of family-centered care?

Correct answer: D

Rationale: Family-centered care focuses on respecting family autonomy, providing flexible services, and collaborating with family members to ensure individualized care. Imposing strict rules contradicts the core principles of family-centered care, which prioritize partnership, communication, and shared decision-making between healthcare providers and families. Therefore, setting strict rules for families to follow goes against the collaborative and individualized nature of family-centered care, making it the statement that is not a principle of this approach.

3. A nurse is caring for a child who has a new diagnosis of osteomyelitis. Which of the following actions should the nurse take?

Correct answer: C

Rationale: The nurse should monitor the child’s weight daily to assess the effectiveness of treatment for osteomyelitis and detect potential complications.

4. Which is the priority nursing assessment when providing care for an infant at risk for dehydration?

Correct answer: D

Rationale: The correct answer is Daily weight. Daily weight is a crucial assessment in infants at risk for dehydration because changes in weight can indicate fluid balance and dehydration status. It is essential to monitor daily weight to promptly identify and manage dehydration in infants.

5. A patient is prescribed Lisinopril as part of the treatment plan for heart failure. Which finding indicates the patient is experiencing the therapeutic effect of this drug?

Correct answer: C

Rationale: The correct answer is C. Lisinopril, an ACE inhibitor, promotes venous dilation, which helps reduce pulmonary congestion and peripheral edema. The absence of previously heard crackles in the lungs indicates effectiveness in reducing pulmonary congestion. Edema and jugular vein distention are signs of heart failure and would not indicate the therapeutic effect of Lisinopril. A potassium level of 3.5mEq/L is within the normal range and not directly related to the therapeutic effect of Lisinopril.

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