ATI RN
Nursing Care of Children Final ATI
1. A two-month-old infant who has gastroesophageal reflux is thriving without other complications. Which instruction should the nurse include in the teaching plan?
- A. Place the infant in the Trendelenburg position after feeding
- B. Thicken formula with rice cereal
- C. Give continuous nasogastric feedings
- D. Give larger, less frequent feeds
Correct answer: B
Rationale: The correct instruction for a two-month-old infant with gastroesophageal reflux who is thriving without complications is to thicken the formula with rice cereal. This can help reduce reflux by increasing the weight of the formula, making it less likely to be regurgitated. Placing the infant in the Trendelenburg position after feeding (Choice A) is not recommended as it can increase the risk of aspiration. Continuous nasogastric feedings (Choice C) are not typically indicated for uncomplicated reflux in infants. Giving larger, less frequent feeds (Choice D) can worsen reflux symptoms by overloading the stomach.
2. A nurse is caring for a client who has a fecal impaction. Which action should the nurse take when digitally evacuating the stool?
- A. Insert a lubricated gloved finger and advance along the rectal wall
- B. Apply lubricant and stimulate peristalsis
- C. Apply pressure to the abdomen to assist with removal
- D. Increase fluid intake before the procedure
Correct answer: A
Rationale: The correct action when digitally evacuating a fecal impaction is to insert a lubricated gloved finger and advance along the rectal wall. This technique helps prevent trauma and effectively dislodge the impacted stool. Choice B, applying lubricant and stimulating peristalsis, is incorrect as it does not directly address the evacuation of the impacted stool. Choice C, applying pressure to the abdomen, is inappropriate and may cause discomfort or harm to the client. Choice D, increasing fluid intake before the procedure, is not directly related to the immediate evacuation of the fecal impaction.
3. Which mineral is a principal component of cell membranes?
- A. phosphorus
- B. magnesium
- C. iron
- D. iodine
Correct answer: A
Rationale: Phosphorus is the correct answer. It is a key component of cell membranes, being part of the phospholipid bilayer that provides structure and controls the movement of substances in and out of cells. Magnesium, iron, and iodine do not serve as principal components of cell membranes. Magnesium is involved in various enzymatic reactions, iron is essential for oxygen transport, and iodine plays a role in thyroid hormone synthesis.
4. The nurse has given instructions to the client with an ileostomy about foods to eat to thicken the stool. The nurse determines that the client needs further instructions if the client stated to eat which of the following foods to make the stool less watery?
- A. Pasta
- B. Boiled rice
- C. Bran
- D. Low-fat cheese
Correct answer: C
Rationale: Foods that help to thicken the stool of the client with an ileostomy include pasta, boiled rice, and low-fat cheese. Bran is high in dietary fiber and thus will increase the output of watery stool by increasing propulsion through the bowel. Ileostomy output is liquid. Addition or elimination of various foods can help to thicken or loosen this liquid drainage.
5. A school nurse is providing care for students in an elementary education facility. Which of the following interventions by the nurse addresses the primary level of prevention?
- A. Design interventions for a student's individual education plan (IEP).
- B. Teach students about healthy food choices.
- C. Perform first aid for minor injuries.
- D. Perform scoliosis screenings for students.
Correct answer: B
Rationale: The correct answer is B because teaching students about healthy food choices is a primary prevention strategy that aims to prevent future health issues by promoting healthy behaviors. Choice A, designing interventions for an individual education plan (IEP), is more related to addressing specific educational needs rather than preventing health issues. Choice C, performing first aid for minor injuries, is a form of secondary prevention aimed at reducing the impact of existing health problems. Choice D, performing scoliosis screenings for students, falls under secondary prevention by detecting health issues early rather than preventing them.