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. The nurse is taking a health history of an adolescent. Which best describes how the chief complaint should be determined?
- A. Request a detailed listing of symptoms.
- B. Ask the adolescent, "Why did you come here today?"
- C. Interview the parent away from the adolescent to determine the chief complaint
- D. Use what the adolescent says to determine, in correct medical terminology, what the problem is
Correct answer: B
Rationale: Asking the adolescent directly about the reason for their visit encourages open communication and helps the nurse understand the primary concern from the patient's perspective.
3. The nurse is caring for a child with acute renal failure. What laboratory findings should the nurse expect to find? (Select all that apply.)
- A. Hyponatremia
- B. Hyperkalemia
- C. All are applicable
- D. Elevated blood urea nitrogen level
Correct answer: C
Rationale: In acute renal failure, laboratory findings typically include hyperkalemia, hyponatremia, and elevated blood urea nitrogen (BUN) levels due to the kidneys' inability to excrete waste and balance electrolytes. Metabolic alkalosis is less common, with metabolic acidosis being more typical.
4. What condition is often associated with severe diarrhea?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct answer: A
Rationale: Severe diarrhea can lead to a loss of bicarbonate, resulting in metabolic acidosis. This is a common complication of prolonged or severe diarrhea, especially in children.
5. Which of the following conditions is characterized by a 'machine-like' murmur in children?
- A. Patent ductus arteriosus
- B. Ventricular septal defect
- C. Atrial septal defect
- D. Coarctation of the aorta
Correct answer: A
Rationale: The correct answer is A, Patent ductus arteriosus. This condition is characterized by a continuous 'machine-like' murmur due to abnormal blood flow between the aorta and pulmonary artery. Ventricular septal defect (choice B) is characterized by a harsh holosystolic murmur, atrial septal defect (choice C) typically presents with a fixed split S2 and a pulmonary flow murmur, and coarctation of the aorta (choice D) is associated with a systolic murmur in the back and bilateral lower extremities.
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