the nurse is preparing to complete documentation on a patients chart which should be included in documentation of nursing care select all that apply
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Nursing Elites

ATI RN

Nursing Care of Children Final ATI

1. The nurse is preparing to complete documentation on a patient's chart. Which should be included in documentation of nursing care? (Select all that apply.)

Correct answer: D

Rationale: Proper documentation includes reassessments, initial assessments, care provided, and the patient's response, but incident reports are typically documented separately.

2. The clinic nurse is reviewing the immunization guidelines for hepatitis B. Which are true of the guidelines for this vaccine?

Correct answer: B

Rationale: Hepatitis B vaccination should start at birth, and any child or adolescent not vaccinated should complete the series. Adolescents should receive three doses if they were not previously vaccinated.

3. The nurse is discussing issues that are important with parents considering a cross-racial adoption. Which statement made by the parents indicates further teaching is needed?

Correct answer: C

Rationale: The statement about making sure others realize the child is part of the family may indicate a focus on external validation rather than on the child’s needs and identity, suggesting a need for further teaching.

4. A parent asks the nurse what would be the first indication that acute glomerulonephritis was improving. What would be the nurse's best response?

Correct answer: D

Rationale: Increased urine output is often the first sign that acute glomerulonephritis is improving, as it indicates a reduction in fluid retention and better kidney function. Stabilization of blood pressure and other symptoms typically follow.

5. The nurse is caring for a child after a cleft palate repair who is on a clear liquid diet. Which feeding device should the nurse use to deliver the clear liquid diet?

Correct answer: D

Rationale: An open cup is recommended for feeding after cleft palate repair to prevent injury to the surgical site and avoid creating negative pressure, which could disrupt the repair.

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