ATI RN
Nursing Care of Children ATI
1. The nurse is preparing to administer a measles, mumps, rubella, and varicella (MMRV) vaccine. Which is a contraindication associated with administering this vaccine?
- A. The child has recently been exposed to an infectious disease
- B. The child has symptoms of a cold but no fever
- C. The child is having intermittent episodes of diarrhea
- D. The child has a disorder that causes a deficient immune system
Correct answer: D
Rationale: A compromised immune system is a contraindication for the MMRV vaccine because it is a live attenuated vaccine and could potentially cause an infection in an immunocompromised child.
2. Your patient has a GI tract that is functioning, but has the inability to swallow foods. Which is the preferred method of feeding for your patient?
- A. TPN
- B. PPN
- C. NG feeding
- D. Oral liquid supplements
Correct answer: C
Rationale: NG feeding is the preferred method for patients with a functioning GI tract but an inability to swallow foods.
3. You’re advising a 21 y.o. with a colostomy who reports problems with flatus. What food should you recommend?
- A. Peas
- B. Cabbage
- C. Broccoli
- D. Yogurt
Correct answer: D
Rationale: Yogurt can help reduce problems with flatus in patients with a colostomy.
4. In what significant way should the therapeutic environment differ for a client who has ingested LSD from that of a client who has ingested PCP?
- A. For LSD ingestion, maintain a regimen of limited interaction and minimal verbal stimulation. For PCP ingestion, place client on one-on-one intensive supervision.
- B. For LSD ingestion, place the client in restraints. For PCP ingestion, place the client on seizure precautions.
- C. For LSD ingestion, provide continual medieval simulation involving as many senses as possible. For PCP ingestion, provide continual high-level stimulation.
- D. For PCP ingestion, place the client on one-on-one intensive supervision. For LSD ingestion, maintain a regimen of limited interaction and minimal verbal stimulation.
Correct answer: For PCP ingestion, place client on one-on-one intensive supervision. For LSD ingestion, maintain a regimen of limited interaction and minimal verbal stimulation.
Rationale: When managing a client who has ingested PCP, it is crucial to provide one-on-one intensive supervision to ensure their safety and prevent any harm to themselves or others. This level of supervision is necessary due to the unpredictable and potentially dangerous effects of PCP. On the other hand, for a client who has ingested LSD, it is recommended to maintain a calm environment with limited interaction and minimal verbal stimulation. This approach aims to prevent exacerbating any adverse effects of LSD, such as anxiety or paranoia, by reducing external stimuli. Therefore, the correct approach is to provide one-on-one intensive supervision for PCP ingestion and limit interaction and verbal stimulation for LSD ingestion.
5. A nurse is observing a nursing student practicing standard precautions. Which observation by the instructor indicates that further teaching is necessary?
- A. The nursing student wears gloves when changing bed linens.
- B. The nursing student wears gloves to remove a wound dressing.
- C. The nursing student washes hands after removing gloves.
- D. The nursing student touches the patient's skin with sterile gloves.
Correct answer: D
Rationale: The correct answer is D because touching a patient's skin with sterile gloves compromises the sterility of the gloves, increasing the risk of contamination. Choices A, B, and C demonstrate correct practices in standard precautions. Wearing gloves when changing bed linens and to remove a wound dressing, as well as washing hands after removing gloves, are all appropriate and necessary steps to prevent the spread of infection.
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