ATI RN
RN Nursing Care of Children 2019 With NGN
1. A six-year-old child is admitted to the hospital with a diagnosis of urinary tract infection. Which of these factors contribute to urinary tract infections in young children?
- A. Excessive intake of carbonated beverages.
- B. Insufficient water intake to flush the kidneys.
- C. Voiding pattern of 5-6 times a day.
- D. Infrequent voiding which results in urinary stasis.
Correct answer: D
Rationale: Infrequent voiding can lead to urinary stasis, which increases the risk of urinary tract infections by allowing bacteria to multiply in the bladder. Encouraging regular voiding and proper hydration can help prevent UTIs. Choices A, B, and C are incorrect. Excessive intake of carbonated beverages may irritate the bladder but is not a direct cause of UTIs. Insufficient water intake can concentrate urine but does not necessarily lead to infections. A voiding pattern of 5-6 times a day is within the normal range and is not associated with increased UTI risk.
2. What is a common factor related to all forms of heart failure?
- A. Peripheral edema
- B. Pulmonary edema
- C. Reduced cardiac output
- D. Jugular vein distention
Correct answer: C
Rationale: The correct answer is C: Reduced cardiac output. All forms of heart failure share this common factor, which occurs when the heart is unable to pump enough blood to meet the body's needs. Choices A, B, and D are incorrect. While peripheral edema and pulmonary edema can be symptoms of heart failure, they are not universal to all forms. Jugular vein distention is a sign of right heart failure, not a common factor across all types of heart failure.
3. The health care provider's progress note for a patient states that the complete blood count (CBC) shows a 'shift to the left.' Which assessment finding will the nurse expect?
- A. Cool extremities
- B. Pallor and weakness
- C. Elevated temperature
- D. Low oxygen saturation
Correct answer: C
Rationale: The correct answer is C: Elevated temperature. When a CBC shows a 'shift to the left,' it indicates elevated levels of immature polymorphonuclear neutrophils (bands), which is a sign of infection. In response to the infection, the body increases its temperature as part of the immune response. Choices A, B, and D are incorrect because cool extremities, pallor and weakness, and low oxygen saturation are not typically associated with a 'shift to the left' in a CBC; they are more indicative of other conditions or issues.
4. A nurse is providing discharge teaching to a client who is postpartum and has a prescription for methylergonovine. The nurse should instruct the client to report which of the following adverse effects?
- A. Headache
- B. Diarrhea
- C. Nausea
- D. Increased vaginal bleeding
Correct answer: A
Rationale: The correct answer is A: Headache. Methylergonovine can cause vasoconstriction, leading to headaches. It is important for the client to report this adverse effect to the provider as it may indicate a serious complication. Choices B, C, and D are incorrect because methylergonovine is not typically associated with diarrhea, nausea, or increased vaginal bleeding as common adverse effects.
5. You are preparing a patient for surgery and completing the preoperative checklist. Which of the following is not typically part of the preoperative checklist?
- A. Assessing for allergies
- B. Conducting the Time Out
- C. Ensuring that informed consent is signed
- D. Ensuring that the history and physical examination have been completed
Correct answer: B: Conducting the Time Out
Rationale: Conducting the Time Out is a crucial safety step that occurs immediately before the start of the procedure, but it is not usually part of the preoperative checklist. The Time Out involves verifying patient identity, correct procedure, correct site, and addressing any concerns or questions with the surgical team before proceeding. The other options, such as assessing for allergies, ensuring informed consent, and completing the history and physical examination, are typically included in the preoperative checklist to ensure patient safety and readiness for surgery.