ATI RN
RN Nursing Care of Children Online Practice 2019 A
1. The presence of which pair of factors is a good predictor of a fluid deficit of at least 5% in an infant?
- A. Weight loss and decreased heart rate
- B. Capillary refill of less than 2 seconds and no tears
- C. Increased skin elasticity and sunken anterior fontanel
- D. Dry mucous membranes and generally ill appearance
Correct answer: D
Rationale: Dry mucous membranes and an ill appearance are good indicators of dehydration in infants, often correlating with a fluid deficit of at least 5%. Sunken fontanels and poor skin turgor are also indicative but were not options here.
2. A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets. After securing the client's airway and initiating an IV, which of the following actions should the nurse do next?
- A. Monitor the client's IV site for thrombophlebitis.
- B. Administer flumazenil to the client.
- C. Evaluate the client for further suicidal behavior.
- D. Initiate seizure precautions for the client.
Correct answer: B
Rationale: Administering flumazenil is the priority to reverse the effects of diazepam overdose. Flumazenil is a specific benzodiazepine receptor antagonist that can rapidly reverse the sedative effects of diazepam. Monitoring the IV site for thrombophlebitis is important but not the immediate priority in this situation. Evaluating the client for further suicidal behavior is important for comprehensive care but is not the most urgent action at this moment. Initiating seizure precautions may be necessary, but the priority is to counteract the sedative effects of diazepam with flumazenil.
3. A nurse is caring for a newborn who is 1-day-old and receiving phototherapy for jaundice. Which of the following actions should the nurse take?
- A. Feed the infant 30 ml (1 oz) of glucose water every 2 hours.
- B. Keep the infant's head covered with a cap.
- C. Ensure that the newborn wears a diaper.
- D. Apply lotion to the newborn every 4 hours.
Correct answer: C
Rationale: The correct action for the nurse to take is to ensure that the newborn wears a diaper. This is important to prevent skin irritation during phototherapy. Choice A is incorrect as newborns should be breastfed or formula-fed, not given glucose water. Choice B is unnecessary and may interfere with the effectiveness of phototherapy. Choice D is inappropriate as lotions can interfere with the phototherapy and increase the risk of skin damage.
4. When teaching a parent of a child with contact dermatitis, which instruction should the nurse include?
- A. Apply a thick layer of antibiotic ointment to the affected area.
- B. Rub the skin vigorously with a towel to dry it.
- C. Keep the child's skin dry.
- D. Apply a thin layer of corticosteroid cream to the affected area.
Correct answer: D
Rationale: The correct instruction for a child with contact dermatitis is to apply a thin layer of corticosteroid cream to the affected area. Corticosteroid cream helps reduce inflammation and itching associated with contact dermatitis. It is important to avoid using antibiotic ointment or rubbing the skin vigorously, as these can worsen the condition. Keeping the child's skin dry is generally a good practice, but in the case of contact dermatitis, corticosteroid cream application is more beneficial.
5. In negative feedback mechanisms, changes away from the normal state
- A. stimulate changes in the same direction
- B. inhibit all body reactions
- C. stimulate changes in the opposite direction
- D. stimulate a reduction in all body requirements
Correct answer: stimulate changes in the opposite direction
Rationale: In negative feedback mechanisms, changes away from the normal state stimulate changes in the opposite direction. This is a fundamental concept in biological systems where the response to a stimulus opposes the initial change, helping to maintain homeostasis. Choice A is incorrect because negative feedback does not stimulate changes in the same direction. Choice B is incorrect because negative feedback does not inhibit all body reactions, but rather specific responses. Choice D is incorrect because negative feedback does not stimulate a reduction in all body requirements, but rather adjusts specific functions to restore balance.
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