ATI RN
ATI Nursing Care of Children 2019 B
1. An infant is born with a gastroschisis. Care preoperatively should include which priority intervention?
- A. Prone position
- B. Sterile water feedings
- C. Monitoring serum laboratory electrolytes
- D. Covering the defect with a sterile bowel bag
Correct answer: D
Rationale: The correct priority intervention for an infant with gastroschisis is to cover the exposed abdominal contents with a sterile bowel bag. This action helps protect the intestines from injury, contamination, and dehydration before surgical repair. Choice A, placing the infant in the prone position, is not appropriate as it does not address the immediate need to protect the exposed intestines. Choice B, sterile water feedings, and Choice C, monitoring serum laboratory electrolytes, are not the priority interventions for this condition. Sterile water feedings may not provide the necessary protection for the exposed intestines, and monitoring electrolytes, while important, is secondary to the immediate need for protection and hydration of the exposed abdominal contents.
2. A nurse is preparing a sterile field for a client with a surgical wound. Which of the following actions should the nurse take to maintain the sterile field?
- A. Open sterile packages using the flap closest to your body first.
- B. Don sterile gloves before opening the sterile package.
- C. Avoid reaching over the sterile field.
- D. Place sterile items at least 2.5 cm (1 in) from the edge of the sterile field.
Correct answer: C
Rationale: The correct action to maintain a sterile field is to avoid reaching over it. This prevents contamination of the sterile environment by reducing the risk of unintentionally dropping microorganisms from non-sterile areas onto the sterile field. Opening sterile packages using the flap closest to your body first (choice A) is a good practice but not directly related to maintaining the sterile field. Donning sterile gloves before opening the sterile package (choice B) is crucial for maintaining sterility but not specific to maintaining the sterile field. Placing sterile items at least 2.5 cm (1 in) from the edge of the sterile field (choice D) is important to prevent accidental contamination, but it is not the primary action to maintain the sterile field.
3. Which of the following statements made by a client diagnosed with human immunodefiency virus (HIV) would require further teaching?
- A. “I will have to be careful and avoid crowds.”
- B. “I will take prescribed medications.”
- C. “I will have to take medications for the rest of my life.”
- D. “I will only need to take HIV medications for 6 months, and I will be cured
Correct answer: “I will only need to take HIV medications for 6 months, and I will be cured
Rationale:
4. A nurse is assessing a client who is 4 hours postpartum. Which of the following findings should the nurse report to the provider?
- A. Lochia that is red and contains small clots.
- B. Fundus firm at the umbilicus.
- C. Fundus deviated to the right.
- D. Moderate perineal pain with swelling.
Correct answer: C
Rationale: The correct answer is C. A fundus that is deviated to the right may indicate a full bladder, which should be addressed postpartum. Choice A is incorrect because red lochia with small clots is expected during the early postpartum period. Choice B is incorrect as the fundus should be firm and midline, not at the umbilicus. Choice D is incorrect as perineal pain and swelling are common postpartum findings that do not require immediate reporting to the provider.
5. A client prescribed sertraline for depression is receiving discharge instructions. Which statement by the client indicates an accurate understanding of the medication?
- A. I should take this medication at bedtime to avoid nausea.
- B. I should avoid drinking alcohol while taking this medication.
- C. I should take this medication with food to avoid stomach upset.
- D. It may take several weeks for this medication to be effective.
Correct answer: D
Rationale: The correct answer is D because sertraline, used for depression, typically takes several weeks to become effective. It is important for clients to understand this delayed onset of action to manage their expectations and continue taking the medication as prescribed despite not seeing immediate results.
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