ATI RN
RN Nursing Care of Children 2019 With NGN
1. What measure of fluid balance status is most useful in a child with acute glomerulonephritis?
- A. Proteinuria
- B. Daily weight
- C. Specific gravity
- D. Intake and output
Correct answer: B
Rationale: Daily weight is the most accurate measure of fluid balance in children with acute glomerulonephritis, as it reflects changes in body fluid status more reliably than other measures like proteinuria or specific gravity.
2. The __________ reflex helps a newborn find the nipple.
- A. rooting
- B. Moro
- C. Babinski
- D. tonic neck Answer: A Page Ref: 101 Skill Level: Understand Topic: The Newborn Baby’s Capacities Difficulty Level: Moderate
Correct answer: A
Rationale: The rooting reflex is the correct answer. This reflex helps a newborn baby find the nipple by turning their head and opening their mouth when their cheek is stroked or touched. This is crucial for the baby to locate and latch onto the mother's breast for feeding. The rooting reflex typically disappears around 4 months of age.
3. Electrolytes create _____, which is caused by water following electrolytes within or between cells.
- A. energy
- B. active transport
- C. passive diffusion
- D. osmotic pressure
Correct answer: D
Rationale: Osmotic pressure is the force that drives water movement across cell membranes due to the presence of electrolytes, helping to balance fluid levels in the body. Choice A, 'energy,' is incorrect as electrolytes do not directly create energy. Choice B, 'active transport,' refers to the movement of molecules across a cell membrane requiring energy, not the movement of water. Choice C, 'passive diffusion,' is the process by which substances move from an area of higher concentration to lower concentration, not related to the movement of water following electrolytes.
4. Upon admission, a client diagnosed with major depressive disorder needs the nurse to implement which of the following interventions first?
- A. Administer an antidepressant medication.
- B. Establish a trusting relationship with the client.
- C. Develop a plan of care with the client.
- D. Teach the client about the importance of medication compliance.
Correct answer: B
Rationale: The initial intervention the nurse should prioritize is to establish a trusting relationship with the client. Building trust is fundamental in fostering effective therapeutic communication and providing quality care. This foundational step lays the groundwork for further assessment, collaboration on care plans, and promoting treatment adherence. Administering medication or discussing compliance should come after the establishment of trust to ensure the client feels supported and understood.
5. A child is being treated for dehydration with intravenous fluids. The child currently weighs 13 kg and is estimated to have lost 7% of his normal body weight. The nurse is double-checking the IV rate the healthcare provider prescribed. The formula the healthcare provider used was for maintenance fluids: 1000 mL for 10 kg of body weight plus 50 mL for every kilogram over 10 for 24 hours. Replacement fluid is the percentage of lost body weight � 10 per kg of body weight. According to the calculation for maintenance plus replacement fluid, which hourly IV rate will the nurse implement for 24 hours?
- A. 88 mL/hr
- B. 86 mL/hr
- C. 81 mL/hr
- D. 83 mL/hr
Correct answer: B
Rationale: For 13 kg, the maintenance fluid is 1150 mL (1000 mL for first 10 kg + 3*50 mL for the remaining 3 kg). Replacement fluid is 910 mL (0.07 * 13000 mL). Total fluid is 2060 mL, divided by 24 hours is 86 mL/hr.
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