ATI RN
Nursing Care of Children ATI
1. Latex allergy is suspected in a child with spina bifida. What are appropriate nursing interventions to include in care of this patient?
- A. Avoid using any latex product.
- B. Use only non-allergenic latex products.
- C. Teach the family about long-term management of asthma.
- D. Administer medication for long-term desensitization.
Correct answer: A
Rationale: The correct answer is A: 'Avoid using any latex product.' In the case of a suspected latex allergy, it is crucial to prevent exposure to latex products to avoid allergic reactions. Choice B is incorrect because there are no truly non-allergenic latex products. Choice C is irrelevant to the situation described in the question, as the child does not have asthma. Choice D is also incorrect because desensitization is not an immediate option for managing a suspected latex allergy.
2. The nurse on the postsurgical unit received a client who was transferred from the post-anesthesia care unit (PACU) and is planning care for this client. The nurse understands that staff should begin planning for this client’s discharge at which point during the hospitalization?
- A. Is admitted to the surgical unit
- B. Is transferred from the PACU to the postsurgical unit
- C. Is able to perform activities of daily living independently
- D. Has been assessed by the healthcare provider for the first time after surgery
Correct answer: A
Rationale: Discharge planning should begin as soon as the patient is admitted to the surgical unit to ensure a smooth transition. It is important to start early to address any potential barriers to discharge, coordinate resources, and provide adequate education and support. Choices B, C, and D are not the appropriate points to start discharge planning as they do not mark the beginning of the hospitalization phase related to the surgical unit.
3. What soft tissue musculoskeletal injury is excessive stretching of a ligament?
- A. Sprain
- B. Ligament tear
- C. Strain
- D. Tendon rupture
Correct answer: A
Rationale: A sprain is an injury involving excessive stretching of a ligament.
4. A nurse is creating a plan of care for an oncology patient and one of the identified nursing diagnoses is risk for infection related to myelosuppression. What intervention addresses the leading cause of infection-related death in oncology patients?
- A. Encourage several small meals daily.
- B. Provide skin care to maintain skin integrity.
- C. Assist the patient with hygiene, as needed.
- D. Assess the integrity of the patient’s oral mucosa regularly.
Correct answer: B
Rationale: In oncology patients, particularly those undergoing chemotherapy or radiation therapy, myelosuppression (the decrease in bone marrow activity that leads to reduced white blood cells, red blood cells, and platelets) increases the risk of infection. Maintaining skin integrity is crucial because the skin acts as the body's first line of defense against infections. If the skin becomes compromised, such as through radiation burns, rashes, or breakdowns, it provides a potential entry point for pathogens, increasing the risk of infection. Since infections in oncology patients can quickly become severe due to their weakened immune systems, maintaining skin integrity is a critical intervention to reduce infection risk, especially for patients who are immunosuppressed.
5. The healthcare professional working in the PACU is aware that which of the following procedures may contribute to extracellular losses?
- A. Removal of an ingrown toenail
- B. Tooth extraction
- C. Abdominal surgery
- D. Cataract surgery
Correct answer: C
Rationale: Fluid loss from the extracellular compartment can be caused by abdominal surgery as it involves opening the abdominal cavity, potentially leading to significant fluid losses. Choices A, B, and D do not typically result in substantial extracellular losses compared to abdominal surgery.