ATI RN
Nursing Care of Children ATI
1. An infant weighed 8 lb at birth and was 18 inches in length. What weight and length should the infant be at 5 months of age?
- A. 12 lb, 20 inches
- B. 14 lb, 21.5 inches
- C. 16 lb, 23 inches
- D. 18 lb, 24.5 inches
Correct answer: C
Rationale: By 5 months, an infant's weight should typically double from birth, and length should increase by approximately 50%.
2. The client has been diagnosed with hemorrhoids. Which statement from the client indicates that further teaching is needed?
- A. “I should increase fruits, bran, and fluids in my diet.”
- B. “I will use warm compresses and take sitz baths daily.”
- C. “I must take a laxative every night and have a stool daily.”
- D. “I can use an analgesic ointment or suppository for pain.”
Correct answer: C
Rationale: Choice C indicates the need for further teaching because regular use of laxatives can lead to dependence and is not recommended for hemorrhoids. Increased fiber intake and fluid consumption (Choice A) help prevent constipation, warm compresses and sitz baths (Choice B) provide relief, and using analgesic ointments or suppositories (Choice D) can help manage pain associated with hemorrhoids.
3. A nurse is caring for a client who has a new prescription for warfarin. Which of the following laboratory values should the nurse monitor to determine the effectiveness of the medication?
- A. Hemoglobin
- B. Platelet count
- C. Prothrombin time (PT)
- D. International normalized ratio (INR)
Correct answer: D
Rationale: The correct answer is D, International normalized ratio (INR). INR is used to monitor the therapeutic effect of warfarin, an anticoagulant medication. Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors. Monitoring the INR helps assess how well the medication is working to prevent blood clots. Choices A, B, and C are not specific indicators for monitoring the effectiveness of warfarin. Hemoglobin levels primarily assess the oxygen-carrying capacity of red blood cells, platelet count evaluates the clotting ability of blood, and PT measures the time it takes for blood to clot. While these values are important for overall health assessment, they do not directly reflect the anticoagulant effects of warfarin.
4. A client presents to the emergency department with complaints of chest pain and shortness of breath. The client's ECG shows ST-segment elevation. What is the priority nursing intervention?
- A. Administer aspirin as prescribed.
- B. Prepare the client for emergent coronary angiography.
- C. Administer oxygen therapy.
- D. Initiate CPR.
Correct answer: B
Rationale: In a client presenting with chest pain, shortness of breath, and ST-segment elevation on ECG, the priority nursing intervention is to prepare the client for emergent coronary angiography. This procedure is crucial in diagnosing and treating acute myocardial infarction promptly. Administering aspirin (Choice A) is important but not the priority over emergent coronary angiography. Administering oxygen therapy (Choice C) is supportive but does not address the underlying cause of the ST-segment elevation. Initiating CPR (Choice D) is not the priority in this scenario as the client is stable and conscious.
5. The nurse is performing a colostomy irrigation on a client. During the irrigation, a client begins to complain of abdominal cramps. Which of the following is the most appropriate nursing action?
- A. Notify the physician
- B. Increase the height of the irrigation
- C. Stop the irrigation temporarily.
- D. Medicate with dilaudid and resume the irrigation
Correct answer: C
Rationale: If a client experiences abdominal cramps during a colostomy irrigation, it is appropriate to stop the irrigation temporarily to allow the cramps to subside.
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