ATI RN
Nursing Care of Children ATI
1. An infant, age 5 months, is brought to the clinic by his parents for a well-baby checkup. What is the best advice that the nurse should include at this time about injury prevention?
- A. Keep buttons, beads, and other small objects out of his reach.
- B. Do not permit him to chew paint from window ledges because he might absorb too much lead.
- C. When he learns to roll over, you must supervise him whenever he is on a surface from which he might fall.
- D. Lock the crib sides securely because he may stand and lean against them and fall out of bed.
Correct answer: A
Rationale: Small objects are a choking hazard for infants, so it is crucial to keep them out of reach to prevent injury.
2. Your patient recently had abdominal surgery and tells you that he feels a popping sensation in his incision during a coughing spell, followed by severe pain. You anticipate an evisceration. Which supplies should you take to his room?
- A. A suture kit.
- B. Sterile water and a suture kit.
- C. Sterile water and sterile dressings.
- D. Sterile saline solution and sterile dressings.
Correct answer: D
Rationale: For a suspected evisceration, sterile saline solution and sterile dressings should be taken to the patient's room to cover the wound and keep it moist.
3. Before administering an intermittent tube feeding through a nasogastric tube, the nurse assesses for gastric residual. The nurse understands that this procedure is important to
- A. Confirm proper nasogastric tube placement.
- B. Observe gastric contents.
- C. Assess fluid and electrolyte status.
- D. Evaluate absorption of the last feeding.
Correct answer: D
Rationale: Evaluating the absorption of the last feeding is important because administration of a tube feeding to a full stomach could result in overdistention, thus predisposing the client to regurgitation and possible aspiration.
4. What lab value is a priority in monitoring a patient with HIV?
- A. CD4 T-cell count below 180 cells/mm3
- B. Hemoglobin levels
- C. Serum albumin levels
- D. White blood cell count
Correct answer: A
Rationale: The correct answer is A: CD4 T-cell count below 180 cells/mm3. Monitoring the CD4 T-cell count is crucial in patients with HIV as it reflects the status of the immune system. A CD4 T-cell count below 180 cells/mm3 indicates severe immunocompromise and an increased risk of opportunistic infections. This value guides the initiation of prophylaxis for infections and the timing of antiretroviral therapy initiation. Choices B, C, and D are not the priority lab values in monitoring patients with HIV. Hemoglobin levels primarily assess for anemia, serum albumin levels reflect nutritional status, and white blood cell count is more generalized and may not specifically indicate the severity of immunocompromise in HIV patients.
5. Why is the administration of benzene hexachloride (Lindane) for the treatment of scabies applied in small quantities?
- A. Excessive applications will lead to central nervous system toxicity.
- B. Excessive applications will cause irritation, rash, and inflammation.
- C. Excessive applications will cause headaches, dizziness, and diarrhea.
- D. Excessive applications will lead to anorexia and cachexia.
Correct answer: A
Rationale: The rationale for instructing the patient to apply benzene hexachloride (Lindane) in small quantities for scabies treatment is that excessive applications can lead to central nervous system toxicity. Lindane is a neurotoxin, and overuse or incorrect application can result in adverse effects on the central nervous system, such as seizures, dizziness, and even death. Choices B, C, and D are incorrect because they do not reflect the specific toxic effects associated with Lindane, which primarily affects the central nervous system rather than causing skin irritation, gastrointestinal symptoms, or metabolic issues.
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