ATI RN
Nursing Care of Children Final ATI
1. Why is it difficult to assess a child’s dietary intake?
- A. No systematic assessment tool has been developed
- B. Biochemical analysis for assessing nutrition is expensive
- C. Families usually do not understand much about nutrition
- D. Recall of food consumption is frequently unreliable
Correct answer: D
Rationale: The correct answer is D. Recall of food intake, especially amounts eaten, is often unreliable. While systematic tools like the 24-hour recall and dietary history questionnaires exist, recall can still be challenging in accurately assessing a child's dietary intake. Choices A, B, and C are incorrect because systematic assessment tools do exist, biochemical analysis is not the primary method for dietary assessment, and families' understanding of nutrition may vary but is not the main reason for the difficulty in assessing a child's dietary intake.
2. A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome (ARDS). Which of the following statements by the newly licensed nurse indicates understanding of the teaching?
- A. This medication is given to treat infection.
- B. This medication is given to facilitate ventilation.
- C. This medication is given to decrease inflammation.
- D. This medication is given to reduce anxiety.
Correct answer: This medication is given to facilitate ventilation.
Rationale: Vecuronium is a neuromuscular blocking agent that is used to facilitate ventilation by inducing muscle paralysis, which can help improve oxygenation in patients with ARDS. It does not treat infection, decrease inflammation, or reduce anxiety. Understanding the purpose of vecuronium administration is crucial for providing safe and effective care to patients with respiratory distress.
3. The nurse develops a plan of care for a client with a T tube. Which one of the following nursing interventions should be included?
- A. Inspect skin around the T tube daily for irritation.
- B. Irrigate the T tube every 4 hours to maintain patency.
- C. Maintain the client in a supine position while the T tube is in place.
- D. Keep the T tube clamped except during mealtimes.
Correct answer: A
Rationale: The correct nursing intervention to include in the plan of care for a client with a T tube is to inspect the skin around the T tube daily for irritation. Bile is erosive and can cause skin irritation, so it is crucial to keep the skin clean and dry. T tubes are not routinely irrigated; irrigation is done only with a physician's order. It is unnecessary to maintain the client in a supine position; instead, assist the client into a position of comfort. T tubes are not typically clamped unless ordered by a physician, and if clamped, it is usually done 1 to 2 hours before and after meals.
4. The nurse has completed an education program on normal communication abilities in the preschool-age child. Which statement by a participant indicates a need for further education?
- A. When my child counts numbers, it is only to 10 and we are slowly working on counting higher.
- B. I am glad to know that my 4-year-old child asking so many questions is normal.
- C. Stating his name and address is too hard for my 5-year-old child; it will be another year before he can do that.
- D. My child is finally talking in a way that most of my friends can understand her speech.
Correct answer: C
Rationale: The correct answer is C. By age 5, children should be able to state their name and address. If a child cannot do this, it may indicate a developmental delay that requires further assessment. Choices A, B, and D do not indicate a need for further education as they reflect typical developmental milestones for preschool-age children, such as gradually improving counting skills, asking many questions, and improving speech clarity over time.
5. A nurse is reviewing the laboratory report of a client who has been receiving lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect?
- A. Withhold the next dose.
- B. Increase the dosage.
- C. Discontinue the medication.
- D. Administer the medication.
Correct answer: D
Rationale: Administering the medication is appropriate for a stable lithium level of 0.8 mEq/L. A level of 0.8 mEq/L falls within the therapeutic range for lithium, indicating that the client is receiving an adequate dose to maintain therapeutic effects. Withholding the next dose, increasing the dosage, or discontinuing the medication would not be indicated at this lithium level as it is within the desired range for therapeutic benefit. Therefore, the correct action would be to continue administering the medication to ensure the client maintains the therapeutic level of lithium.