ATI RN
RN Nursing Care of Children Online Practice 2019 A
1. What illnesses does respiratory hygiene and cough etiquette by the Centers for Disease Control and Prevention (CDC) prevent?
- A. HBV, Hib, and pertussis
- B. HSV, influenza, and HBV
- C. RSV, influenza, and adenovirus
- D. RSV, pertussis, and varicella
Correct answer: C
Rationale: The correct answer is C: RSV, influenza, and adenovirus. The CDC recommends respiratory hygiene and etiquette to prevent the transmission of respiratory syncytial virus (RSV), influenza, adenovirus, and other droplet-transmitted unknown viruses. Choices A, B, and D are incorrect because HBV, Hib, pertussis, HSV, and varicella are not typically transmitted via droplets but through other modes of transmission.
2. A healthcare professional is preparing to administer packed red blood cells (PRBCs) to a client. Which of the following actions should the healthcare professional take?
- A. Infuse the PRBCs over 8 hours.
- B. Verify the client's blood type and Rh factor.
- C. Administer the PRBCs through a 24-gauge catheter.
- D. Administer the PRBCs with lactated Ringer's solution.
Correct answer: B
Rationale: Verifying the client's blood type and Rh factor is crucial before administering blood products to ensure compatibility and prevent adverse reactions. Option A is incorrect because PRBCs are typically infused over a specific time frame based on hospital policy and client condition, not necessarily over 8 hours. Option C is incorrect as PRBCs are usually administered through a larger gauge catheter to prevent hemolysis. Option D is incorrect because PRBCs are typically administered with normal saline and not lactated Ringer's solution.
3. What is the best way to assess for fluid overload in a patient with heart failure?
- A. Check daily weight
- B. Check blood pressure
- C. Monitor heart sounds
- D. Assess for jugular vein distention
Correct answer: A
Rationale: The correct answer is to 'Check daily weight.' Monitoring daily weight is the most accurate method to assess for fluid overload in patients with heart failure. Weight gain can indicate fluid retention, a common issue in heart failure patients. Checking blood pressure (Choice B) can provide information about hemodynamic status but may not be as specific for fluid overload as monitoring weight. Monitoring heart sounds (Choice C) can provide information about cardiac function but may not directly assess fluid overload. Assessing for jugular vein distention (Choice D) can be a sign of increased central venous pressure but may not always correlate with fluid overload as accurately as daily weight checks.
4. During which step of the nursing process does the nurse analyze data related to the patient's health status?
- A. Assessment
- B. Implementation
- C. Diagnosis
- D. Evaluation
Correct answer: A
Rationale: The correct answer is 'Assessment.' During the assessment phase of the nursing process, the nurse collects and analyzes data related to the patient's health status. This involves gathering information through various means such as patient interviews, physical examinations, and reviewing medical records. Choice B, 'Implementation,' refers to the phase where the nurse carries out the planned interventions. Choices C and D, 'Diagnosis' and 'Evaluation,' come after the assessment phase in the nursing process.
5. A child is being cared for by a nurse and has rheumatic fever. Which of the following actions should the nurse plan to take?
- A. Administer aspirin to the child as prescribed based on the healthcare provider's instructions.
- B. Encourage adequate fluid intake for the child.
- C. Elevate the child's joints and provide warm compresses.
- D. Monitor the child's heart rate for dysrhythmias.
Correct answer: D
Rationale: Rheumatic fever can lead to cardiac complications, such as dysrhythmias. Therefore, it is essential for the nurse to monitor the child's heart rate closely for any signs of dysrhythmias. This will help in early identification and prompt management of potential cardiac issues associated with rheumatic fever. Choices A, B, and C are not the priority actions in this scenario. While aspirin may be used in the treatment of rheumatic fever, monitoring for cardiac complications takes precedence. Encouraging fluid intake and providing warm compresses are helpful interventions but do not directly address the cardiac risks associated with rheumatic fever.