ATI RN
Nursing Care of Children Final ATI
1. The school nurse is assessing children for risk factors related to childhood injuries. Which child has the most risk factors related to childhood injury?
- A. Female, multiple siblings, stable home life
- B. Male, high activity level, stressful home life
- C. Male, even-tempered, history of previous injuries
- D. Female, reacts negatively to new situations, no serious previous injuries
Correct answer: B
Rationale: A male child with a high activity level and a stressful home life has multiple risk factors for childhood injuries, requiring closer supervision and preventive measures.
2. A client is admitted with superior vena cava syndrome. What action by the nurse is most appropriate?
- A. Administer a dose of allopurinol.
- B. Assess the client’s serum potassium level.
- C. Gently inquire about advance directives.
- D. Prepare the client for emergency surgery.
Correct answer: C
Rationale: The correct answer is to gently inquire about advance directives. Superior vena cava syndrome is often a late-stage manifestation, indicating a serious condition. Discussing advance directives with the client is crucial to ensure their wishes are known in case of deterioration. Administering allopurinol (Choice A) is not indicated for superior vena cava syndrome. Assessing the client’s serum potassium level (Choice B) is not the priority when managing this syndrome. Emergency surgery (Choice D) is not typically the initial treatment for superior vena cava syndrome.
3. How should a healthcare professional educate a patient on the use of an incentive spirometer?
- A. Instruct the patient to take deep breaths
- B. Instruct the patient to cough forcefully
- C. Instruct the patient to blow into the spirometer
- D. Instruct the patient to use the spirometer every hour
Correct answer: D
Rationale: Instructing the patient to use the spirometer every hour is crucial for optimal lung expansion and to prevent postoperative pulmonary complications. This regular use helps to keep the lungs clear and maintain their capacity. Choices A, B, and C are incorrect because deep breathing, forceful coughing, and blowing into the spirometer do not specifically address the proper use of the incentive spirometer, which is essential for postoperative respiratory recovery.
4. Which statement demonstrates a well-structured attempt at limit setting?
- A. Hitting me when you are angry is unacceptable.
- B. I expect you to behave yourself during dinner.
- C. Come here, right now!
- D. Good boys don't bite.
Correct answer: A
Rationale: Choice A, 'Hitting me when you are angry is unacceptable,' demonstrates a well-structured attempt at limit setting because it clearly defines the unacceptable behavior without ambiguity. This statement sets a clear boundary and clearly communicates the consequence for the behavior. In contrast, choices B, C, and D are less effective in setting limits as they are either vague expectations or commands without specific consequences for crossing the limit.
5. A client is prescribed 1g of potassium phosphate IV to be infused continuously over 6 hr. Available is 1 g in 250 ml of dextrose 5%. What rate should the nurse set the IV pump to run at?
- A. 40 ml/hr
- B. 42 ml/hr
- C. 44 ml/hr
- D. 46 ml/hr
Correct answer: B
Rationale: To calculate the IV rate, divide the total volume by the total time in hours. In this case, 1 g in 250 ml is to be infused over 6 hours. Therefore, 250 ml / 6 hr = 42 ml/hr. This means the IV pump should be set to run at 42 ml/hr. Choices A, C, and D are incorrect as they do not accurately calculate the infusion rate based on the provided information.
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