ATI RN
RN Nursing Care of Children 2019 With NGN
1. When assessing a child with leukemia, which clinical manifestations should the nurse anticipate?
- A. Petechiae, fever, fatigue
- B. Headache, papilledema, irritability
- C. Muscle wasting, weight loss, fatigue
- D. Decreased intracranial pressure, psychosis, confusion
Correct answer: A
Rationale: The correct answer is A: Petechiae, fever, fatigue. Children with leukemia commonly present with petechiae (due to low platelet count), fever (due to infection), and fatigue (due to anemia), which are classic manifestations of the disease. Option B is incorrect because headache, papilledema, and irritability are more indicative of increased intracranial pressure, not leukemia. Option C is incorrect as muscle wasting and weight loss are not typical initial manifestations of leukemia in children. Option D is incorrect as decreased intracranial pressure, psychosis, and confusion are not commonly associated with leukemia.
2. A client is prescribed Spironolactone. Which of the following laboratory findings should the nurse monitor and report to the provider?
- A. Sodium level of 138 mEq/L
- B. Potassium level of 5.2 mEq/L
- C. Chloride level of 100 mEq/L
- D. Calcium level of 9.5 mg/dL
Correct answer: B
Rationale: Spironolactone is a potassium-sparing diuretic, causing potassium retention, potentially leading to elevated potassium levels. A potassium level of 5.2 mEq/L is above the normal range (3.5-5.0 mEq/L), indicating hyperkalemia, a serious condition. Elevated potassium levels can lead to life-threatening cardiac arrhythmias. Monitoring and reporting high potassium levels promptly to the healthcare provider are crucial to prevent potential complications. Sodium, chloride, and calcium levels are not directly influenced by Spironolactone, making choices A, C, and D incorrect.
3. A nurse in a clinic is caring for a client who has a urinary tract infection (UTI). Which of the following prescriptions should the nurse verify with a provider?
- A. Trimethoprim-sulfamethoxazole
- B. Hyoscyamine
- C. Oxybutynin
- D. Phenazopyridine
Correct answer: C
Rationale: The correct answer is C, Oxybutynin. Oxybutynin can worsen urinary retention, so the nurse should verify this prescription with the provider. Trimethoprim-sulfamethoxazole (Choice A) is a common antibiotic used to treat UTIs and does not require verification. Hyoscyamine (Choice B) is an anticholinergic medication used for bladder spasms and does not typically worsen UTI symptoms. Phenazopyridine (Choice D) is a urinary analgesic that helps relieve pain, burning, and discomfort caused by a UTI, which may not necessarily require verification in this scenario.
4. A client experiences difficulty breathing after the change of shift. The nurse on duty discovers that the IVFs were infusing at a rate 10 times the calculated normal. After notifying the physician and correcting the rate, what should be the next step in the client's care?
- A. Notify family
- B. Discipline the previous nurse
- C. Complete an incident report
- D. Obtain legal consultation
Correct answer: C
Rationale: The correct next step in the client's care after notifying the physician and correcting the rate of IVFs is to complete an incident report. This report is essential for documenting the adverse event, analyzing the cause, and implementing preventive measures to avoid similar incidents in the future. Notifying the family, disciplining the previous nurse, and obtaining legal consultation are not immediate priorities in this situation. Family notification may follow the incident report, disciplining the previous nurse is a separate administrative process, and legal consultation is usually not required for a medical error corrected promptly.
5. A nurse is completing a nutritional assessment of an adult female client. Which of the following findings should indicate to the nurse that the client is at an increased risk of developing cancer?
- A. Eats at least 5 servings of fruits and vegetables daily.
- B. Eats 6 servings of whole grains daily.
- C. Limits alcohol consumption to 2 drinks per day.
- D. Limits red meat intake to 3oz per day.
Correct answer: C
Rationale: Limiting alcohol consumption to 2 drinks per day is still above the recommended limit for reducing cancer risk; the recommendation is 1 drink per day for women.