ATI RN
ATI Nursing Care of Children
1. What is the appropriate site to administer an intramuscular (IM) vaccine to a newborn?
- A. The dorsal gluteal muscle
- B. The vastus lateralis muscle
- C. The ventral gluteal muscle
- D. The biceps muscle
Correct answer: B
Rationale: The correct site to administer an intramuscular (IM) vaccine to a newborn is the vastus lateralis muscle. For newborns, the vastus lateralis is preferred over the dorsogluteal site because the dorsogluteal site has been associated with low antibody seroconversion rates, indicating a reduced immune response. The vastus lateralis is also recommended for IM injections in newborns, while the deltoid muscle is preferred for older infants and children. The ventral gluteal muscle and the biceps muscle are not appropriate sites for IM injections. Therefore, choice B is the correct answer.
2. The physician orders a maintenance dose of 5,000 units of subcutaneous heparin (an anticoagulant) daily. Nursing responsibilities for Mrs. Mitchell now include:
- A. Reviewing daily activated partial thromboplastin time (APTT) and prothrombin time.
- B. Reporting an APTT above 45 seconds to the physician
- C. Assessing the patient for signs and symptoms of frank and occult bleeding
- D. All of the above
Correct answer: D
Rationale: The correct answer is D. When a physician orders a maintenance dose of subcutaneous heparin, nursing responsibilities include reviewing daily activated partial thromboplastin time (APTT) and prothrombin time to monitor the patient's coagulation status, reporting an APTT above 45 seconds to the physician as it may indicate a risk of bleeding, and assessing the patient for signs and symptoms of frank and occult bleeding, which are potential adverse effects of anticoagulant therapy. Therefore, all the options listed are essential nursing responsibilities when a patient is on subcutaneous heparin therapy.
3. A patient has impaired skin integrity, and a nurse is providing care. What action should the nurse take to promote healing?
- A. Apply a dry, sterile dressing to the wound.
- B. Use sterile saline to clean the wound.
- C. Apply a warm compress to promote circulation.
- D. Keep the wound open to air for faster healing.
Correct answer: B
Rationale: The correct action to promote healing in a patient with impaired skin integrity is to use sterile saline to clean the wound. Sterile saline helps prevent infection and promotes healing of wounds by keeping the area clean. Applying a dry, sterile dressing (Choice A) may not be effective as it does not address the need for wound cleaning. Applying a warm compress (Choice C) may not be suitable for all types of wounds and could potentially cause harm. Keeping the wound open to air (Choice D) is generally not recommended as it can lead to infection and slow down the healing process.
4. Which chronic respiratory condition is characterized by the narrowing and inflammation of the airways, leading to difficulty breathing?
- A. Asthma
- B. COPD
- C. Bronchitis
- D. Pneumonia
Correct answer: A
Rationale: Asthma is the correct answer. It is a chronic respiratory condition where the airways become inflamed and narrowed, leading to episodes of wheezing, breathlessness, chest tightness, and coughing. Asthma is characterized by reversible airflow obstruction, differentiating it from COPD, which involves irreversible airflow limitation. Bronchitis is an inflammation of the bronchial tubes without the same reversible airflow obstruction seen in asthma. Pneumonia is an infection of the lung tissue and does not involve chronic inflammation and narrowing of the airways like asthma.
5. What is the rationale in the use of bag technique during home visits?
- A. It helps render effective nursing care to clients or other members of the family
- B. It saves time and effort of the nurse in the performance of nursing procedures
- C. It should minimize or prevent the spread of infection from individuals to families
- D. It should not overshadow concerns for the patient
Correct answer: C
Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.