the nurse is caring for a child on bed rest who has severe edema in a left lower extremity due to blocked lymphatic drainage which nursing diagnosis w
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Nursing Elites

ATI RN

ATI Pediatric Proctored Exam 2023

1. The healthcare provider is caring for a child on bed rest who has severe edema in the left lower extremity due to blocked lymphatic drainage. Which nursing diagnosis would take priority?

Correct answer: A

Rationale: The priority nursing diagnosis in this scenario is 'Risk for Impaired Skin Integrity' because severe edema in the left lower extremity can lead to compromised circulation and pressure ulcers, increasing the risk of skin breakdown and infection. Addressing and preventing impaired skin integrity is crucial for the child's overall health and well-being.

2. A toddler is admitted to the surgical unit for a planned closure of a temporary colostomy. Which medical prescription should the nurse question?

Correct answer: C

Rationale: The correct answer is C. Rectal temperatures should be avoided in a toddler with a colostomy due to the risk of injury. Choices A, B, and D are appropriate medical prescriptions for a toddler undergoing colostomy closure. Choice A ensures the toddler's intake of clear liquids before being made NPO, choice B prepares for possible blood transfusion needs, and choice D initiates intravenous hydration with D5NS at an appropriate rate.

3. A parent of a child with celiac disease is receiving teaching from a nurse. Which of the following statements should the nurse make?

Correct answer: B

Rationale: The correct answer is B. Celiac disease requires a strict gluten-free diet to manage the condition effectively. Gluten-containing foods like wheat, barley, and rye must be avoided to prevent intestinal damage and symptoms in individuals with celiac disease. Therefore, the nurse should emphasize the importance of a gluten-free diet to the parent of the child with celiac disease.

4. The healthcare provider is planning care for a patient receiving morphine sulfate via a patient-controlled analgesia pump. Which intervention may be required due to a potential adverse effect of this drug?

Correct answer: B

Rationale: Morphine can lead to urinary retention and urinary hesitancy. If a patient shows signs of bladder distention or inability to void, the healthcare provider should be notified, and urinary catheterization may be necessary. Administering a cough suppressant or an anti-diarrheal is not typically required to address adverse effects of morphine. Liver function tests (LFTs) are not directly related to the potential adverse effects of morphine on the urinary system.

5. The patient with bipolar disorder is being treated with lithium and has a new prescription for captopril for hypertension. The combination of these two drugs makes which assessment particularly important?

Correct answer: B

Rationale: When captopril, an ACE inhibitor, is combined with lithium, it can lead to lithium accumulation. Therefore, monitoring lithium levels is crucial to prevent toxicity. While ACE inhibitors like captopril can cause hyperkalemia, renal insufficiency, and hypotension, the risk of these effects is not increased by the combination of lithium and captopril.

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