ATI RN
Nursing Care of Children Final ATI
1. What is an important intervention in providing a neutral thermal environment for an LBW infant in an incubator?
- A. Use wool blankets.
- B. Avoid using disposable diapers.
- C. Prevent heat loss.
- D. Closely monitor both incubator and rectal temperatures.
Correct answer: C
Rationale: Preventing heat loss in a low birth weight (LBW) infant is crucial in maintaining a neutral thermal environment. The use of cotton blankets is recommended over wool blankets. Avoiding disposable diapers is not directly related to maintaining a neutral thermal environment. While monitoring temperatures is important, the key intervention is preventing heat loss to ensure the infant's survival.
2. When assessing a preschooler's chest, what should the nurse expect?
- A. Respiratory movements to be chiefly thoracic
- B. Anteroposterior diameter to be equal to the transverse diameter
- C. Retraction of the muscles between the ribs on respiratory movement
- D. Movement of the chest wall to be symmetric bilaterally and coordinated with breathing
Correct answer: D
Rationale: In a preschooler, chest movement should be symmetric and coordinated with breathing, indicating healthy respiratory function.
3. When educating a parent of a child with HIV, which statement indicates an understanding of the teaching?
- A. I will notify my child's school about their condition.
- B. I will give my child the prescribed antiretroviral medication at regular intervals.
- C. I will expect my child to receive yearly immunizations.
- D. I will bring my child in for yearly skin testing.
Correct answer: B
Rationale: The correct answer is B because ensuring the child receives the prescribed antiretroviral medication at regular intervals is crucial in maintaining therapeutic levels and preventing drug resistance in a child with HIV. Choices A, C, and D are incorrect because notifying the school about the condition, expecting yearly immunizations, and bringing the child in for yearly skin testing do not directly address the essential aspect of medication adherence, which is fundamental in managing HIV in children.
4. A client is receiving opioid analgesics for pain management. Which of the following assessments is the priority?
- A. Monitor the client's blood pressure.
- B. Check the client's urinary output.
- C. Monitor the client's respiratory rate.
- D. Assess the client's pain level.
Correct answer: C
Rationale: The correct answer is C: Monitor the client's respiratory rate. When a client is receiving opioid analgesics, the priority assessment is monitoring respiratory rate. Opioids can cause respiratory depression, so it is crucial to assess the client's breathing to detect any signs of respiratory distress promptly. Checking the client's blood pressure (Choice A) and urinary output (Choice B) are important assessments too, but they are not the priority when compared to ensuring adequate respiratory function. Assessing the client's pain level (Choice D) is essential for overall care but is not the priority assessment when the client is on opioids, as respiratory status takes precedence.
5. What interventions should be implemented to maintain the skin integrity of a preterm infant born at 30 weeks?
- A. Avoid cleaning the skin
- B. Bathe the infant with sterile water
- C. Cleanse the skin with a gentle alkaline-based soap and water
- D. Thoroughly rinse the skin with plain water after bathing
Correct answer: B
Rationale: The correct intervention to maintain the skin integrity of a preterm infant born at 30 weeks is to bathe the infant with sterile water. Bathing with sterile water or a neutral pH solution is recommended to protect the delicate skin of preterm infants, which is more permeable and prone to damage. Choices A, C, and D are incorrect as avoiding cleaning the skin may lead to hygiene issues, cleansing with alkaline-based soap can be harsh on the delicate skin, and thoroughly rinsing with plain water after bathing may not be as gentle and protective for preterm infants.