ATI RN
RN Nursing Care of Children Online Practice 2019 A
1. The nurse is selecting a site to begin an intravenous infusion on a 2-year-old child. The superficial veins on his hand and arm are not readily visible. What intervention should increase the visibility of these veins?
- A. Gently tap over the site.
- B. Apply a cold compress to the site.
- C. Raise the extremity above the level of the body
- D. Use a rubber band as a tourniquet for 5 minutes.
Correct answer: A
Rationale: Gently tapping over the site helps dilate the veins and increase visibility. Applying a cold compress or raising the extremity above the body level constricts the veins, making them harder to access. Prolonged tourniquet use can cause discomfort and venous congestion.
2. A nurse is assessing a client who has just returned from surgery and is experiencing acute pain. Which of the following findings should the nurse expect?
- A. Bradycardia.
- B. Hypotension.
- C. Diaphoresis.
- D. Hyperactive bowel sounds.
Correct answer: C
Rationale: The correct answer is C: Diaphoresis. Diaphoresis, which is excessive sweating, is a common response to acute pain due to increased sympathetic nervous system activity. Options A and B, Bradycardia and Hypotension, are unlikely findings in a client experiencing acute pain as pain usually triggers an increase in heart rate (tachycardia) and blood pressure. Option D, Hyperactive bowel sounds, is not typically associated with acute pain.
3. Which nursing diagnosis has nutritional implications?
- A. impaired dentition
- B. disruption of gas exchange
- C. self-esteem disturbance
- D. sleep pattern disturbance
Correct answer: A
Rationale: Impaired dentition affects a patient's ability to chew and consume a variety of foods, leading to potential nutritional deficiencies and malnutrition.
4. In caring for an adolescent with severe abdominal pain due to appendicitis, where should the nurse identify as McBurney's point?
- A. Right lower quadrant
- B. Left lower quadrant
- C. Right upper quadrant
- D. Left upper quadrant
Correct answer: A
Rationale: McBurney's point is located in the right lower quadrant of the abdomen, specifically between the umbilicus and the anterior iliac crest. This point is significant in diagnosing appendicitis, as tenderness at McBurney's point is a classic sign of appendicitis and indicates inflammation near the appendix. Therefore, the correct answer is the 'Right lower quadrant.' Choices B, C, and D are incorrect because McBurney's point is not located in the left lower quadrant, right upper quadrant, or left upper quadrant of the abdomen.
5. 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.
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