ATI RN
ATI Nursing Care of Children 2019 B
1. The nurse is caring for an infant who had surgical repair of a tracheoesophageal fistula 24 hours ago. Gastrostomy feedings have not been started. What do nursing actions related to the gastrostomy tube include?
- A. Keep the tube clamped.
- B. Suction the tube as needed.
- C. Leave the tube open to gravity drainage.
- D. Secure the tube with tape.
Correct answer: C
Rationale: Leaving the gastrostomy tube open to gravity drainage prevents the accumulation of air and fluids, reducing the risk of complications such as vomiting or aspiration in the immediate postoperative period. Keeping the tube clamped or suctioning it can lead to pressure buildup, increasing the risk of complications. Securing the tube with tape is important but not the primary action related to the gastrostomy tube in this case.
2. What important point should the nurse emphasize about taking oral contraceptives consistently?
- A. Oral contraceptives must be taken at the same time each day to maintain consistent hormone levels and ensure effectiveness in preventing pregnancy.
- B. Oral contraceptives should be taken in the morning to avoid side effects at night.
- C. Oral contraceptives should be taken with food to enhance absorption.
- D. Oral contraceptives can be skipped occasionally without significant consequences.
Correct answer: A
Rationale: The correct answer is A. It is crucial for patients taking oral contraceptives to take them at the same time each day to maintain consistent hormone levels, which is essential for their effectiveness in preventing pregnancy. Choice B is incorrect as the timing of the medication is more about consistency than avoiding side effects at night. Choice C is incorrect as oral contraceptives do not necessarily need to be taken with food for absorption. Choice D is incorrect because skipping oral contraceptives occasionally can significantly reduce their effectiveness in preventing pregnancy.
3. What is the initial major sign of acute renal failure?
- A. Oliguria
- B. Hematuria
- C. Proteinuria
- D. Glycosuria
Correct answer: A
Rationale: Oliguria, or reduced urine output, is often the initial major sign of acute renal failure. This reduction in urine output indicates that the kidneys are not functioning properly. Hematuria (blood in urine), proteinuria (presence of protein in urine), and glycosuria (presence of glucose in urine) are not typically the initial major signs of acute renal failure. While they may be present in certain conditions, oliguria is the most common and critical indicator of acute renal failure.
4. A nurse is providing discharge teaching to a client who has a new prescription for digoxin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will take my pulse before taking this medication.
- B. I should take this medication with food to prevent nausea.
- C. I will take this medication if my heart rate is less than 60/min.
- D. I should take this medication with food if I am not feeling well.
Correct answer: A
Rationale: The correct answer is A. Taking the pulse before taking digoxin is crucial as it helps monitor the heart rate, as digoxin can cause bradycardia as a side effect. Option B is incorrect because digoxin should be taken on an empty stomach to enhance absorption. Option C is incorrect because digoxin should be held and the healthcare provider should be contacted if the heart rate is less than 60/min. Option D is incorrect because digoxin should not be taken with food due to decreased absorption.
5. An RN comes upon a serious motor vehicle accident that has just occurred and no first responders are on the scene. One car has been flipped upside down, and she can see the driver still in the car. The RN decides to stop and help. She knows she is protected from civil liability as long as she does which of the following?
- A. Acts in an ordinary, reasonable, and prudent professional manner
- B. Assures that information obtained is not communicated to anyone else
- C. Does not make any verbal comments that could lead to economic harm
- D. Fails to meet the established standards of practice
Correct answer: A
Rationale: The correct answer is A: 'Acts in an ordinary, reasonable, and prudent professional manner.' In emergency situations, healthcare professionals are protected from civil liability as long as they act in a manner that any other reasonable and prudent professional would under similar circumstances. Choice B is incorrect because communication of relevant information is essential for patient care and handover to other healthcare providers. Choice C is incorrect as it pertains to a different issue of preventing economic harm rather than addressing the immediate medical needs of the injured driver. Choice D is incorrect because failing to meet established standards of practice can lead to liability, especially in emergencies where immediate action is required to save lives.
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