ATI RN
ATI Nursing Care of Children
1. The nurse is assessing a child's capillary refill time. This can be accomplished by doing what?
- A. Inspect the chest
- B. Auscultate the heart
- C. Palpate the apical pulse
- D. Palpate the nail bed with pressure to produce a slight blanching
Correct answer: D
Rationale: Capillary refill time is assessed by applying pressure to the nail bed and observing how quickly the color returns, indicating peripheral circulation status.
2. What is the major cause of death for children older than 1 year in the United States?
- A. Heart disease
- B. Childhood cancer
- C. Unintentional injuries
- D. Congenital anomalies
Correct answer: C
Rationale: Unintentional injuries are the leading cause of death among children older than 1 year in the United States.
3. The nurse is preparing to administer a measles, mumps, rubella, and varicella (MMRV) vaccine. Which is a contraindication associated with administering this vaccine?
- A. The child has recently been exposed to an infectious disease
- B. The child has symptoms of a cold but no fever
- C. The child is having intermittent episodes of diarrhea
- D. The child has a disorder that causes a deficient immune system
Correct answer: D
Rationale: A compromised immune system is a contraindication for the MMRV vaccine because it is a live attenuated vaccine and could potentially cause an infection in an immunocompromised child.
4. The nurse determines that a child's intravenous infusion has infiltrated. The infused solution is a vesicant. What is the most appropriate nursing action?
- A. Stop the infusion and apply ice.
- B. End the infusion and notify the practitioner.
- C. Slow the infusion rate and notify the practitioner.
- D. Discontinue the infusion and apply warm compresses.
Correct answer: B
Rationale: If a vesicant solution infiltrates, stopping the infusion immediately and notifying the practitioner is critical to prevent tissue damage. Cold or warm compresses should only be applied following specific medical advice based on the vesicant involved.
5. The nurse is planning care for a hospitalized preschool-aged child. Which should the nurse plan to ensure atraumatic care?
- A. Limit explanation of procedures because the child is preschool-aged
- B. Ask that all family members leave the room when performing procedures
- C. Allow the child to choose the type of juice to drink with the administration of oral medications
- D. Explain that EMLA cream cannot be used for the morning lab draw because there is not time for it to be effective
Correct answer: C
Rationale: Allowing the child to make choices, such as selecting the type of juice, helps to maintain a sense of control and reduce anxiety, ensuring atraumatic care.
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