ATI RN
ATI Nursing Care of Children 2019 B
1. The child is admitted with acute abdominal pain and possible appendicitis. What intervention is appropriate to relieve the abdominal discomfort during the evaluation?
- A. Place the child in the Trendelenburg position.
- B. Apply moist heat to the abdomen.
- C. Allow the child to assume a position of comfort.
- D. Administer a saline enema to cleanse the bowel.
Correct answer: C
Rationale: Allowing the child to assume a position of comfort is appropriate as it helps alleviate discomfort without the risk of complications. Placing the child in the Trendelenburg position could increase intra-abdominal pressure and worsen the condition. Applying moist heat may lead to vasodilation and potential perforation in case of appendicitis. Administering a saline enema can be harmful if the appendix is inflamed or perforated.
2. What intervention is crucial during a sickle cell crisis in a child?
- A. Administer oxygen
- B. Apply cold compresses
- C. Restrict fluids
- D. Encourage bed rest
Correct answer: A
Rationale: Administering oxygen is crucial during a sickle cell crisis in a child as it helps to prevent further sickling of cells. Oxygen therapy can improve oxygen saturation levels, reducing the risk of tissue damage and complications. Applying cold compresses (choice B) is not recommended as it can potentially worsen vaso-occlusive crisis by causing vasoconstriction. Restricting fluids (choice C) is not appropriate as hydration is essential to prevent dehydration and maintain adequate blood flow. Encouraging bed rest (choice D) may be necessary but administering oxygen takes precedence in managing a sickle cell crisis.
3. What clinical manifestations would the nurse expect to find in a client who is experiencing anaphylaxis?
- A. Dilated bronchioles, constriction of peripheral blood vessels, decreased capillary permeability
- B. Asthma, deep vein thrombosis, hepatic encephalopathy
- C. Narrowing of the bronchioles, dilation of the peripheral blood vessels, increased capillary permeability
- D. Left-sided heart failure, pulmonary embolism, urinary tract infection
Correct answer: C
Rationale: In anaphylaxis, the client would present with narrowing of the bronchioles, dilation of the peripheral blood vessels, and increased capillary permeability. These manifestations lead to symptoms such as difficulty breathing, low blood pressure, and swelling. Choices A, B, and D are incorrect because they do not describe the typical clinical manifestations of anaphylaxis.
4. A client who has a new prescription for lisinopril is being taught by a nurse. Which of the following client statements indicates an understanding of the teaching?
- A. I should avoid using salt substitutes while taking this medication.
- B. I should take this medication with food to prevent nausea.
- C. I should increase my intake of potassium-rich foods while taking this medication.
- D. I should limit my fluid intake while taking this medication.
Correct answer: A
Rationale: The correct answer is A. Lisinopril can increase potassium levels, so clients should avoid salt substitutes that contain potassium. Choice B is incorrect because lisinopril is usually taken on an empty stomach. Choice C is incorrect because lisinopril can lead to hyperkalemia, so increasing potassium-rich foods is not recommended. Choice D is incorrect because lisinopril can cause increased urination, so fluid intake should not be limited.
5. A healthcare professional is educating a client who is starting therapy with topotecan. Which of the following findings should the professional instruct the client to report?
- A. Hair loss
- B. Fatigue
- C. Sore throat
- D. Red urine
Correct answer: C
Rationale: The correct answer is C: 'Sore throat.' Clients starting therapy with topotecan should be instructed to report a sore throat because it can indicate an infection due to the immunosuppressive effects of the medication. Infections can be serious in clients undergoing chemotherapy, so early detection and treatment are crucial to prevent complications. Choices A, B, and D are incorrect because while they are potential side effects of topotecan, they are usually not as immediately concerning as a sore throat, which could signal a serious infection requiring prompt attention.
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