ATI RN
RN Nursing Care of Children 2019 With NGN
1. The parents of a child born with ambiguous genitalia tell the nurse that family and friends are asking what caused the baby to be this way. Tests are being done to assist in gender assignment. What should the nurse's intervention include?
- A. Explain the disorder so they can explain it to others.
- B. Help parents understand that this is a minor problem.
- C. Suggest that parents avoid family and friends until the gender is assigned.
- D. Encourage parents not to worry while the tests are being done.
Correct answer: A
Rationale: It is important for the nurse to provide the parents with accurate information so they can confidently explain the situation to others, helping to reduce stress and misinformation. Avoiding family and friends or minimizing the problem is not helpful.
2. Why does Anita stand in front of the mirror while performing a Breast Self-Examination (BSE)?
- A. To check for unusual discharges from the breast
- B. To check for any obvious malignancy
- C. To observe the size and contour of the breast
- D. To check for thickness and lumps in the breast
Correct answer: C
Rationale: When performing a Breast Self-Examination (BSE), one of the reasons for standing in front of a mirror is to observe the size and contour of the breast (Choice C). This helps in identifying any visible changes or abnormalities such as dimpling, puckering, or changes in the size and shape of the breasts. While unusual discharges (Choice A) and thickness or lumps (Choice D) can be part of the changes a person might notice during a BSE, these are typically identified by palpation or by squeezing the nipple for discharge, not by just looking in the mirror. Choice B, checking for obvious malignancy, is too vague and not specific enough as malignancy is often not visible to the naked eye.
3. While assessing a patient's peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy?
- A. Air emboli
- B. Phlebitis
- C. Infiltration
- D. Fluid overload
Correct answer: C
Rationale: Infiltration is the administration of a nonvesicant solution or medication into the surrounding tissue, typically due to the dislodgement or perforation of the vein wall by the IV cannula. It is characterized by edema around the insertion site, leakage of IV fluid, discomfort, coolness, and a decrease in flow rate. In this scenario, the presence of edema indicates infiltration, not air emboli, phlebitis, or fluid overload. Air emboli refer to air bubbles in the bloodstream, phlebitis is inflammation of the vein, and fluid overload is an excessive volume of fluid in the circulatory system.
4. When reviewing a client's health record, a nurse notes a new prescription for Lisinopril 10 mg PO once daily. The nurse should identify this as which type of prescription?
- A. Single
- B. Stat
- C. Routine
- D. Standing
Correct answer: C
Rationale: A routine prescription indicates medications to be administered on a regular schedule without a termination date or a specific number of doses. In this case, Lisinopril 10 mg PO once daily falls under a routine prescription, meaning the nurse will administer this medication daily until the provider discontinues it. Choices A, B, and D are incorrect: A 'single' prescription is for a one-time dose, 'stat' prescriptions are for immediate administration, and 'standing' prescriptions are pre-authorized for administration as needed within specified parameters.
5. After reviewing the health and dental histories, the dental hygienist has adequate information to begin dietary counseling with the patient. Providing a standardized, low-carbohydrate menu is sufficient for most patients with a high caries rate.
- A. Both statements are true
- B. Both statements are false
- C. The first statement is true; the second is false
- D. The first statement is false; the second is true
Correct answer: B
Rationale: Both statements are false. Dietary counseling should be personalized, and a standardized low-carbohydrate menu is not sufficient for all patients.
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