ATI RN
ATI Nursing Care of Children
1. The nurse's approach when introducing hospital equipment to a preschooler who seems afraid should be based on which principle?
- A. The child may think the equipment is alive.
- B. Explaining the equipment will only increase the child’s fear
- C. One brief explanation will be enough to reduce the child’s fear
- D. The child is too young to understand what the equipment does
Correct answer: A
Rationale: Preschoolers may engage in magical thinking and believe inanimate objects are alive, so the nurse should explain the equipment in a way that reduces fear.
2. Which of the following wounds is most likely to heal by secondary intention?
- A. A finger laceration received while cutting onions
- B. A stage IV pressure ulcer that developed in a nursing home
- C. A needlestick injury received while administering parenteral medication
- D. An incision from an open appendectomy
Correct answer: B
Rationale: A stage IV pressure ulcer is a deep wound involving tissue loss that typically heals by secondary intention. This process involves the wound healing from the bottom up with granulation tissue and often results in significant scarring. Choice A, a finger laceration, would generally heal by primary intention due to its clean edges and minimal tissue loss. Choice C, a needlestick injury, is likely to be sutured and heal by primary intention since it is a small, clean wound. Choice D, an incision from an open appendectomy, is usually closed with sutures and heals by primary intention as well.
3. A nurse is planning care for a client who has a new diagnosis of deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?
- A. Massage the affected extremity to promote circulation.
- B. Elevate the affected extremity.
- C. Apply cold packs to the affected extremity.
- D. Perform range-of-motion exercises on the affected extremity.
Correct answer: C
Rationale: The correct intervention for a client with DVT is to apply cold packs to the affected extremity. Cold packs can help reduce swelling and pain by constricting blood vessels. Massaging the affected extremity can dislodge a clot and worsen the condition. Elevating the affected extremity helps with blood flow but is not the priority intervention for DVT. Performing range-of-motion exercises on the affected extremity can also dislodge a clot and is contraindicated.
4. A client with a long history of smoking is being assessed by a nurse. Which finding is a common complication of chronic obstructive pulmonary disease (COPD)?
- A. Decreased anteroposterior chest diameter
- B. Increased breath sounds
- C. Prolonged expiratory phase
- D. Increased chest expansion
Correct answer: C
Rationale: In COPD, a prolonged expiratory phase is a typical finding caused by airway obstruction and air trapping. This results in difficulty expelling air from the lungs, leading to the characteristic prolonged exhalation in individuals with COPD.
5. The client with chronic pancreatitis needs information on dietary modification to manage the health problem. The nurse teaches the client to limit which of the following items in the diet?
- A. Carbohydrate
- B. Protein
- C. Fat
- D. Water-soluble vitamins
Correct answer: C
Rationale: The client should limit fat in the diet. The client also should take in small meals, which also will reduce the amount of carbohydrates and protein that the client must digest at any one time. The client does not need to limit water-soluble vitamins in the diet.
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