the nurse needs to take the blood pressure of a small child of the cuffs available one is too large and one is too small the best nursing action is wh
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Nursing Elites

ATI RN

ATI Nursing Care of Children

1. The nurse needs to take the blood pressure of a small child. Of the cuffs available, one is too large and one is too small. The best nursing action is which?

Correct answer: D

Rationale: It is essential to use the correct cuff size for accurate blood pressure readings; if the proper size is not available, it's best to wait until it can be obtained.

2. According to Piaget, which principle supports a nine-year-old child's understanding that an arm will look the same when the IV is removed?

Correct answer: A

Rationale: The correct answer is A, the principle of conservation. Piaget's principle of conservation relates to a child's ability to understand that certain properties of objects remain unchanged despite modifications in their appearance. In this case, the child's understanding that an arm will look the same after the IV is removed demonstrates conservation of appearance. Choice B, transductive reasoning, involves making faulty generalizations based on specific instances and does not apply in this context. Choice C, the principle of identity, pertains to recognizing objects as the same even if they undergo transformations, which is not directly relevant to the scenario. Choice D, reflex abilities, refers to automatic responses to stimuli and is unrelated to the child's understanding of the arm's appearance post-IV removal.

3. Which dietary information should the nurse include in the teaching plan for a school-age child with chronic renal failure?

Correct answer: C

Rationale: A low-phosphorus diet is recommended for children with chronic renal failure to prevent hyperphosphatemia, which can lead to bone disease and other complications. Phosphorus is found in many processed foods and should be limited. Choices A, B, and D are incorrect because high sodium intake can lead to fluid retention and hypertension, while Vitamin D supplementation and vitamins C, E, K are not specifically indicated for dietary recommendations in chronic renal failure.

4. 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.

5. What is a priority intervention for an infant with a temporary colostomy for Hirschsprung disease?

Correct answer: B

Rationale: Protecting the skin around the colostomy is crucial to prevent irritation and infection, which are common complications in infants with colostomies. Teaching and discussing long-term implications are important but secondary to immediate skin care needs.

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