ATI RN
RN Nursing Care of Children 2019 With NGN
1. A parent calls the hospital nursing hotline and asks, 'My 8-week-old infant cries 8 hours a day, and is hard to console. Is that normal?' What should the nurse's response be to this parent?
- A. No, call your health care provider.
- B. Let me ask you some more questions to see if there are symptoms of colic.
- C. Yes, maybe your infant is just tired.
- D. Yes, infants cry all the time at that age.
Correct answer: B
Rationale: The correct response for the nurse to provide in this situation is to ask more questions to determine if the infant is displaying symptoms of colic. Colic is a common condition in infants that can lead to prolonged crying and fussiness. It is essential to assess for other symptoms before giving advice to the parent. Choices A, C, and D are incorrect because they do not address the possibility of colic or the need for further assessment of the infant's condition.
2. The college health nurse is providing health education for freshmen. Which of the following pieces of information about immunizations is applicable to individuals of this age group?
- A. The oral polio vaccine should be updated.
- B. The yearly administration of flu vaccine is recommended.
- C. The tetanus toxoid should be within 2 years.
- D. The administration of hepatitis A vaccine is mandatory.
Correct answer: B
Rationale: For freshmen in college, the yearly administration of the flu vaccine is recommended. This is important to protect against seasonal influenza outbreaks that can spread rapidly in close living quarters such as dormitories. Choice A is incorrect as oral polio vaccine is not typically given to individuals of this age group. Choice C is incorrect as tetanus toxoid boosters are usually recommended every 10 years, not within 2 years. Choice D is incorrect as the administration of the hepatitis A vaccine is not mandatory for all individuals in this age group.
3. Which of the following would be an expected nutritional outcome for a client who has undergone a subtotal gastrectomy for cancer?
- A. Regain weight loss within 1 month after surgery
- B. Resume normal dietary intake of three meals per day
- C. Control nausea and vomiting through regular use of antiemetics
- D. Achieve optimal nutritional status through oral or parenteral feedings
Correct answer: D
Rationale: Achieving optimal nutritional status through oral or parenteral feedings is an expected nutritional outcome for a client who has undergone a subtotal gastrectomy for cancer.
4. A client is caring for a postoperative client on the surgical unit. The client's blood pressure was 142/76 mm Hg 30 minutes ago and is now 88/50 mm Hg. What action by the nurse is best?
- A. Call the Rapid Response Team.
- B. Document and continue to monitor.
- C. Notify the primary care provider.
- D. Repeat blood pressure measurement in 15 minutes.
Correct answer: A
Rationale: In this scenario, the significant drop in blood pressure indicates a potential emergency situation. The correct action is to call the Rapid Response Team (RRT) to ensure prompt intervention and prevent further deterioration that could lead to respiratory or cardiac arrest. It is crucial to act swiftly in response to such a critical change in vital signs to provide the client with the necessary care and support.
5. A patient's antiretroviral therapy has not been as efficacious as her care team had predicted, and maraviroc (Selzentry) has consequently been added to her drug regimen. The nurse should recognize this drug as belonging to what category of antiretroviral?
- A. Fusion protein inhibitors
- B. Protease inhibitors
- C. CCR5 antagonists
- D. Integrase strand transfer inhibitors
Correct answer: C
Rationale: Women with a history of breast cancer should avoid hormone replacement therapy due to the increased risk of cancer recurrence.