after surgery yesterday for gastroesophageal reflux the nurse finds that the infant has somehow removed the nasogastric ng tube what nursing action is
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Nursing Elites

ATI RN

ATI Nursing Care of Children 2019 B

1. After surgery yesterday for gastroesophageal reflux, the nurse finds that the infant has somehow removed the nasogastric (NG) tube. What nursing action is most appropriate to perform at this time?

Correct answer: A

Rationale: The most appropriate action for the nurse to take in this situation is to notify the healthcare provider immediately. This is important as the removal of the NG tube can disrupt postoperative care, especially in terms of maintaining gastric decompression. Inserting a new NG tube without practitioner direction can be unsafe and is not within the nurse's scope of practice. Similarly, replacing the NG tube or leaving it out should be decided by the healthcare provider to ensure the infant's safety and appropriate postoperative care.

2. The nurse understands that blocks to therapeutic communication include what? (Select all that apply.)

Correct answer: B

Rationale: Socializing, using clichés, and defending a situation are all barriers to effective therapeutic communication. Silence is a useful tool in therapeutic communication.

3. A mother brings 6-month-old Eric to the clinic for a well-baby checkup. She comments, "I want to go back to work, but I don't want Eric to suffer because I'll have less time with him." Which is the nurse's most appropriate answer?

Correct answer: C

Rationale: The best approach is to discuss childcare options that would suit Eric's needs, allowing the mother to make an informed decision without guilt or pressure.

4. Children may believe that they are responsible for their parents' divorce and interpret the separation as punishment. At which age is this most likely to occur?

Correct answer: C

Rationale: At around 8 years old, children may feel they are responsible for their parents' divorce and view it as a punishment, which can impact their emotional well-being.

5. A child diagnosed with a soft tissue tumor is being treated with chemotherapy. Prior to administering the chemotherapy, which laboratory test should the nurse monitor to determine if the child has any capability of fighting infections?

Correct answer: D

Rationale: The Absolute Neutrophil Count (ANC) is crucial for determining the child's ability to fight infections. Neutrophils play a key role in combating bacterial infections. Monitoring the ANC is essential before administering chemotherapy, as a low ANC indicates an increased risk of infection. Hemoglobin, red blood cell count, and platelets are important for assessing oxygen-carrying capacity, anemia, and clotting function, respectively, but they do not directly reflect the child's capability to fight infections.

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