ATI RN
Nursing Care of Children ATI
1. An infant is diagnosed with a tracheoesophageal fistula. Which assessment finding should the nurse expect?
- A. Jaundice
- B. Hyperactive bowel sounds
- C. Absence of sucking, vomiting
- D. Coughing, with excessive secretion
Correct answer: D
Rationale: Coughing with excessive secretion is a common sign of tracheoesophageal fistula. In this condition, the connection between the trachea and esophagus allows saliva and food to enter the airways, leading to coughing and excessive secretions. Choice A, jaundice, is not typically associated with tracheoesophageal fistula. Hyperactive bowel sounds (Choice B) are more likely seen in conditions like gastroenteritis. Absence of sucking and vomiting (Choice C) is not a typical finding related to tracheoesophageal fistula.
2. A nurse is developing a program about strategies to prevent foodborne illnesses for a community group. The nurse should plan to include which of the following recommendations? (Select one that does not apply).
- A. Keep cold food temperatures below 4.4°C (40°F).
- B. Reheat leftovers before eating.
- C. Wash raw vegetables thoroughly in clean water.
- D. Keep cooked foods at 48.9°C (120°F).
Correct answer: Keep cooked foods at 48.9°C (120°F).
Rationale: The correct answer is to keep cooked foods at 48.9°C (120°F). This temperature is too low to keep cooked foods safe from bacterial growth. The ideal temperature to keep cooked foods safe is above 60°C (140°F). Choices A, B, and C are all important strategies to prevent foodborne illnesses. Keeping cold food temperatures below 4.4°C (40°F) helps prevent bacterial growth, reheating leftovers before eating kills any bacteria that may have grown during storage, and washing raw vegetables thoroughly in clean water helps remove dirt and bacteria.
3. Which statement fosters cultural competence?
- A. Treat everyone the same regardless of their culture
- B. Provide an outline of your beliefs as a starting point
- C. Acknowledge and respond to influences of cultural beliefs in the intervention plan
- D. Ask the family to outline how their beliefs will influence therapy
Correct answer: C
Rationale: Cultural competence involves recognizing and considering the impact of cultural beliefs on individuals. By acknowledging and responding to these cultural influences in the intervention plan, professionals can tailor their approach effectively and respectfully. This approach helps build trust, enhances communication, and improves outcomes in culturally diverse settings.
4. An RN is writing reminders for good documentation for the nurses on her staff. The purpose is to ensure nursing documentation is legally credible. Which of the following is a recommendation she should include in the reminders?
- A. Use shortcuts in documentation.
- B. Only use approved abbreviations.
- C. Documentation should be subjective.
- D. Document after care is provided.
Correct answer: B
Rationale: The correct recommendation that should be included in the reminders for ensuring legally credible nursing documentation is to 'Only use approved abbreviations.' Using shortcuts in documentation (Choice A) may lead to incomplete or vague information, compromising the credibility of documentation. Documentation should not be subjective (Choice C) but rather objective and based on factual information. While it is important to document after care is provided (Choice D), the immediate documentation following care provision is critical for accuracy and legal credibility.
5. A child with acute gastrointestinal bleeding is admitted to the hospital. The nurse observes which sign or symptom as an early manifestation of shock?
- A. Restlessness
- B. Rapid capillary refill
- C. Increased temperature
- D. Increased blood pressure
Correct answer: A
Rationale: Restlessness is an early sign of shock due to decreased perfusion and oxygenation to the brain. This symptom requires immediate attention to prevent the progression to more severe stages of shock. Rapid capillary refill (Choice B) is not typically an early sign of shock but rather a sign of adequate perfusion. Increased temperature (Choice C) may occur in later stages of shock due to the body's response to stress. Increased blood pressure (Choice D) is not an early sign of shock; in fact, blood pressure tends to decrease in shock as a compensatory mechanism.