ATI RN
RN Pediatric Nursing 2023 ATI
1. 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?
- A. Administering a cough suppressant
- B. Inserting a Foley catheter
- C. Administering an anti-diarrheal
- D. Monitoring urinary output
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.
2. The nurse is assessing a client with a history of heart failure who is receiving a unit of packed red blood cells. The client’s respiratory rate is 33 breaths/min and blood pressure is 140/90 mm Hg. Which action does the nurse take first?
- A. Administer prescribed diphenhydramine (Benadryl).
- B. Continue to monitor the client’s vital signs.
- C. Stop the infusion of packed red blood cells.
- D. Slow the infusion rate of the transfusion
Correct answer: Slow the infusion rate of the transfusion
Rationale: In this scenario, the client is showing signs of a potential transfusion reaction, indicated by an increased respiratory rate. The nurse's initial action should be to slow down the infusion rate of the packed red blood cells to prevent further complications. Administering diphenhydramine or stopping the infusion should not be the first actions taken, as the priority is to ensure the client's safety and prevent adverse reactions. Continuing to monitor vital signs without taking immediate action to address the increased respiratory rate would delay appropriate intervention.
3. A nursing student is caring for a patient with acute myeloid leukemia who is preparing to undergo induction therapy. In preparing a plan of care for this patient, the student should assign the highest priority to which nursing diagnosis?
- A. Activity Intolerance
- B. Risk for Infection
- C. Acute Confusion
- D. Risk for Spiritual Distress
Correct answer: B
Rationale: The correct answer is B: Risk for Infection. Induction therapy for acute myeloid leukemia suppresses the immune system, making the patient highly susceptible to infections due to neutropenia. Preventing infections is crucial in these patients to avoid complications. Activity Intolerance (Choice A) may be a concern, but infection prevention is of higher priority. Acute Confusion (Choice C) and Risk for Spiritual Distress (Choice D) are not the immediate priorities in this situation.
4. A patient taking an oral contraceptive missed one pill. What should the nurse teach the patient to do?
- A. Take two pills as soon as you remember, then continue the regular schedule.
- B. Take one pill as soon as you remember, then continue the regular schedule.
- C. Skip the missed pill and continue the regular schedule.
- D. Take two pills immediately, then continue the regular schedule.
Correct answer: A
Rationale: When a patient taking an oral contraceptive misses one pill, the correct action is to take two pills as soon as they remember and then continue the regular schedule. Option A is the correct answer because doubling up the dose helps maintain the effectiveness of the contraceptive. Option B is incorrect because taking only one pill after missing one may decrease contraceptive effectiveness. Option C is wrong as skipping the missed pill can also reduce effectiveness. Option D is inaccurate because taking two pills immediately is not necessary; the patient should take the missed pill as soon as remembered and then resume the regular dosing schedule.
5. A nurse is caring for a 30-month-old toddler and is preparing a nutritional snack. Which of the following foods is appropriate for the nurse to offer the toddler?
- A. Plain popcorn
- B. Grapes
- C. Raw carrots
- D. Cheese
Correct answer: D
Rationale: Cheese is a safe and nutritious option for toddlers as it provides calcium and protein without posing choking hazards. Plain popcorn, grapes, and raw carrots are not recommended for toddlers due to the potential choking risks they present, especially at a young age.
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