ATI RN
RN Nursing Care of Children Online Practice 2019 A
1. During the nurse’s initial assessment of a school-age child, the child reports a pain level of 6 out of 10. The child is lying quietly in bed watching television. What action should the nurse take?
- A. Reassess the child in 15 minutes to see if the pain rating has changed
- B. Administer the prescribed analgesic
- C. Do nothing since the child appears to be resting
- D. Ask the child’s parents if they think the child is hurting
Correct answer: B
Rationale: Pain management should be based on the child’s report of pain, regardless of their activity level. Administering the prescribed analgesic is the appropriate action. Reassessing the child in 15 minutes without providing immediate pain relief may not be in the child's best interest. Doing nothing since the child appears to be resting may lead to inadequate pain management. Asking the child’s parents if they think the child is hurting does not replace the need for direct assessment and intervention by the nurse.
2. What recommendation should the nurse make to prevent urinary tract infections (UTIs) in young girls?
- A. Avoid public toilet facilities
- B. Limit long baths as much as possible
- C. Cleanse the perineum with water after voiding
- D. Ensure clear liquid intake of 2 L/day
Correct answer: C
Rationale: Proper perineal hygiene, including cleansing with water after voiding, is crucial in preventing UTIs in young girls. Avoiding public toilets and limiting baths are less effective than proper hygiene practices.
3. The nurse suspects fluid overload in an infant receiving intravenous fluids. What clinical manifestation is suggestive of water intoxication?
- A. Oliguria
- B. Weight loss
- C. Irritability and seizures
- D. Muscle weakness and cardiac dysrhythmias
Correct answer: C
Rationale: Water intoxication can lead to cerebral edema, causing neurological symptoms such as irritability and seizures. Oliguria, weight loss, and muscle weakness are not typical signs of water intoxication.
4. The nurse is teaching a parent with a 2-month-old infant who has been diagnosed with colic about ways to relieve colic. Which statement by the parent indicates the need for additional teaching?
- A. I should let my infant cry for at least 30 minutes before I respond.
- B. I will swaddle my infant tightly with a soft blanket.
- C. I should massage my infant's abdomen whenever possible.
- D. I will place my infant in an upright seat after feeding.
Correct answer: A
Rationale: Letting an infant cry for prolonged periods can exacerbate colic and increase the infant's distress. It is better to respond promptly to soothe the baby. Other methods like swaddling, gentle massage, and keeping the infant upright can help relieve colic symptoms.
5. What is an approximate method of estimating output for a child who is not toilet trained?
- A. Have parents estimate output.
- B. Weigh diapers after each void.
- C. Place a urine collection device on the child.
- D. Have the child sit on a potty chair 30 minutes after eating.
Correct answer: B
Rationale: Weighing diapers is the most accurate way to estimate urine output in a child who is not toilet trained. This method provides a measurable and reliable estimate of fluid output.