ATI RN
Nursing Care of Children ATI
1. The nurse is teaching a nursing student about standard precautions. Which statement made by the student indicates a need for further teaching?
- A. I will use precautions when I give an infant oral care
- B. I will use precautions when I change an infant's diaper
- C. I will use precautions when I come in contact with blood and body fluids
- D. I will use precautions when administering oral medications to a school-age child
Correct answer: D
Rationale: Standard precautions are necessary when dealing with blood, body fluids, and potentially infectious materials. They are not required for routine administration of oral medications unless there is a potential exposure risk.
2. Which heart sound is produced by vibrations within the heart chambers or in the major arteries from the back-and-forth flow of blood?
- A. S1 and S2
- B. S3 and S4
- C. Murmur
- D. Physiologic splitting
Correct answer: C
Rationale: A murmur is produced by turbulent blood flow within the heart or major arteries, resulting in audible vibrations.
3. After surgery yesterday for gastroesophageal reflux, the nurse finds that the infant has somehow removed the nasogastric (NG) tube. What nursing action is most appropriate to perform at this time?
- A. Notify the healthcare provider.
- B. Insert a new NG tube for feedings.
- C. Replace the NG tube to maintain gastric decompression.
- D. Leave the NG tube out as it may have been in long enough.
Correct answer: A
Rationale: The most appropriate action for the nurse to take in this situation is to notify the healthcare provider immediately. This is important as the removal of the NG tube can disrupt postoperative care, especially in terms of maintaining gastric decompression. Inserting a new NG tube without practitioner direction can be unsafe and is not within the nurse's scope of practice. Similarly, replacing the NG tube or leaving it out should be decided by the healthcare provider to ensure the infant's safety and appropriate postoperative care.
4. Which medication should the nurse expect to administer to a child diagnosed with Nephrotic Syndrome to decrease proteinuria?
- A. Albumin
- B. Prednisone
- C. Penicillin
- D. Furosemide (Lasix)
Correct answer: B
Rationale: Prednisone, a corticosteroid, is the primary treatment for Nephrotic Syndrome as it helps to reduce inflammation in the kidneys and decrease proteinuria by stabilizing the glomerular filtration barrier. Albumin is a protein replacement therapy and would not directly decrease proteinuria. Penicillin is an antibiotic that treats bacterial infections and is not used to manage Nephrotic Syndrome. Furosemide is a diuretic that helps in managing fluid retention but does not specifically target proteinuria in Nephrotic Syndrome.
5. What is an appropriate screening test for hearing that the nurse can administer to a 5-year-old child?
- A. Rinne test
- B. Weber test
- C. Pure tone audiometry
- D. Eliciting the startle reflex
Correct answer: C
Rationale: Pure tone audiometry is an appropriate and effective screening test for hearing in a 5-year-old child, helping to assess the ability to hear various frequencies and volumes.
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