ATI RN
RN Nursing Care of Children 2019 With NGN
1. What are signs and symptoms of a possible kidney transplant rejection in a child? (Select all that apply.)
- A. Fever
- B. Hypotension
- C. All are applicable
- D. Swelling and tenderness of graft area
Correct answer: B
Rationale: Signs of kidney transplant rejection include fever, diminished urinary output, and swelling/tenderness in the graft area. These symptoms indicate that the body may be rejecting the transplanted organ, requiring immediate medical attention.
2. A child with acetylsalicylic acid (aspirin) poisoning is being admitted to the emergency department. What early clinical manifestation does the nurse expect to assess on this child?
- A. Hematemesis
- B. Hematochezia
- C. Hyperglycemia
- D. Hyperventilation
Correct answer: D
Rationale: Early signs of aspirin poisoning include hyperventilation due to the stimulation of the respiratory center and the resultant respiratory alkalosis. Hematemesis, hematochezia, and hyperglycemia can occur later in the poisoning process or may not be directly related to aspirin toxicity.
3. What information should be given to the parents of a 12-month-old child regarding appropriate play activities for this age?
- A. Give large push-pull toys for kinetic stimulation
- B. Place a cradle gym across the crib to help develop fine motor skills
- C. Provide the child with finger paints to enhance fine motor skills
- D. Provide a stick horse to develop gross motor coordination
Correct answer: A
Rationale: Large push-pull toys are suitable for a 12-month-old as they encourage gross motor skills and physical activity, which are crucial for their development at this age.
4. 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?
- A. Use the small cuff
- B. Use the large cuff
- C. Use either cuff using the palpation method
- D. Wait to take the blood pressure until a proper cuff can be located
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.
5. Which immunization should the nurse include in a teaching session for parents of toddler-age clients to decrease the risk for epiglottitis?
- A. Hepatitis B
- B. Polio
- C. Measles, mumps, and rubella (MMR)
- D. Hemophilus influenzae type B (Hib)
Correct answer: D
Rationale: The correct answer is D, Hemophilus influenzae type B (Hib) vaccine. Hib vaccine is crucial in preventing epiglottitis, a serious respiratory condition caused by Haemophilus influenzae type b bacteria. This vaccine is recommended for toddlers to protect them from developing epiglottitis. Choices A, B, and C are incorrect because while they are important vaccines for children, they do not specifically target the prevention of epiglottitis, unlike the Hib vaccine.
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