a nurse is planning care for a school age child who is 2 hours postoperative following a tonsillectomy which of the following actions should the nurse
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Nursing Elites

ATI RN

ATI Pediatric Proctored Exam 2023

1. A school-age child is 2 hours postoperative following a tonsillectomy. Which of the following actions should the nurse include in the plan of care?

Correct answer: D

Rationale: After a tonsillectomy, applying an ice collar to the child's neck helps decrease pain and swelling. Heat should be avoided as it can increase bleeding. Encouraging coughing may increase the risk of bleeding. Administering analgesics on a regular schedule is essential for pain management, but the immediate postoperative period may require additional interventions like ice collar application.

2. In an immunization clinic, which patient will the nurse identify as not eligible to receive routine immunizations?

Correct answer: C

Rationale: The nurse should identify the 4-year-old with a fever and upper respiratory tract infection as not eligible to receive routine immunizations. It is contraindicated to administer vaccines in the presence of moderate to severe illness, whether with or without fever, to prevent potential complications or reduced vaccine efficacy.

3. What does a Z-score of -3.00 indicate?

Correct answer: D

Rationale: A Z-score of -3.00 indicates that the child's performance is significantly below the average of their peers. It represents an extreme low score, indicating a substantial deviation from the mean performance of the group.

4. Which type of play involves actions such as looking and touching the mother's face, putting hands in one's mouth, and responding to familiar people?

Correct answer: A

Rationale: Exploratory play is characterized by exploring sensory experiences and learning about the environment. In this type of play, infants engage in activities like looking, touching, and responding to familiar stimuli to understand the world around them.

5. A healthcare professional is planning care for an infant with hyperbilirubinemia receiving phototherapy. Which of the following actions should the healthcare professional include in the plan?

Correct answer: B

Rationale: Turning and repositioning the infant every 4 hours is essential to prevent pressure sores and ensure uniform exposure to phototherapy. This practice helps prevent skin breakdown and ensures the effectiveness of the phototherapy in treating hyperbilirubinemia. Dressing the infant in light, breathable clothing (Choice A) is generally a good practice but not directly related to the effectiveness of phototherapy. Offering frequent, small feedings (Choice C) is important for infant nutrition but does not directly impact the phototherapy. Avoiding lotions on the infant's skin (Choice D) is recommended to prevent interference with the phototherapy but is not the most critical action to include in the care plan.

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