ATI RN
ATI Nursing Care of Children
1. A thorough systemic physical assessment is necessary in the extremely low-birth-weight (ELBW) infant to detect what?
- A. Weight gain reflective of fluid retention
- B. Difficulties in maternal-child attachment
- C. Subtle changes that may be indicative of an underlying problem
- D. Changes in Apgar score over the first 24 hours of life
Correct answer: C
Rationale: In extremely low-birth-weight (ELBW) infants, a thorough systemic physical assessment is crucial to detect subtle changes that may indicate an underlying problem. These infants are highly vulnerable and may show signs of stress through changes in feeding behavior, activity, color, oxygen saturation, or vital signs. Monitoring weight in ELBW infants primarily reflects genitourinary function rather than fluid retention. Difficulties in maternal-child attachment are important but are usually assessed during parental visits and are not the primary focus of a systemic physical assessment. Changes in the Apgar score are used immediately after birth to assess the transition to extrauterine life and are not as relevant in the following 24 hours to detect ongoing subtle issues.
2. A client who has a new prescription for prednisone is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will avoid taking this medication with food.
- B. I will need to take this medication for the rest of my life.
- C. I will take this medication for 2 weeks and then stop.
- D. I will take this medication with a high-protein snack.
Correct answer: B
Rationale: The correct answer is B because prednisone is usually prescribed for long-term use. Stopping it abruptly can lead to adrenal insufficiency. Choice A is incorrect because prednisone should be taken with food to prevent stomach upset. Choice C is incorrect as prednisone is typically tapered off gradually to avoid adverse effects. Choice D is incorrect as there is no specific requirement to take prednisone with a high-protein snack.
3. You’re preparing a patient with a malignant tumor for colorectal surgery and subsequent colostomy. The patient tells you he’s anxious. What should your initial step be in working with this patient?
- A. Determine what the patient already knows about colostomies.
- B. Show the patient some pictures of colostomies.
- C. Arrange for someone who has a colostomy to visit the patient.
- D. Provide the patient with written material about colostomy care.
Correct answer: A
Rationale: When a patient with a malignant tumor is anxious about colorectal surgery and a colostomy, the initial step is to determine what the patient already knows about colostomies.
4. A client is receiving Enoxaparin for the prevention of deep vein thrombosis. Which of the following actions should the nurse take?
- A. Massage the injection site after administration.
- B. Administer the medication intramuscularly.
- C. Administer the medication into the subcutaneous tissue.
- D. Administer the medication into the deltoid muscle.
Correct answer: C
Rationale: Enoxaparin, a medication used for preventing deep vein thrombosis, should be administered into the subcutaneous tissue, typically in the abdomen. Administering the medication intramuscularly (Choice B) or into the deltoid muscle (Choice D) is incorrect because Enoxaparin is specifically formulated for subcutaneous administration. Massaging the injection site after administration (Choice A) is contraindicated as it may lead to tissue damage and affect the absorption of the medication. Therefore, the correct action is to administer the medication into the subcutaneous tissue as directed.
5. Which of the following is not a side effect associated with Prednisone toxicity?
- A. Cataracts
- B. Hypotension
- C. Psychosis
- D. Acne
Correct answer: B
Rationale: Prednisone toxicity is not typically associated with hypotension; instead, it can lead to hypertension. Cataracts, psychosis, and acne are known side effects of Prednisone toxicity.