ATI RN
RN Nursing Care of Children Online Practice 2019 A
1. When checking the intravenous (IV) site on a child, the nurse should take which action?
- A. Look at the site.
- B. Ask the child if the site hurts.
- C. Look at the site while palpating the area.
- D. Take all the tape off, assess the site, and redress.
Correct answer: C
Rationale: Looking at and palpating the IV site helps assess for signs of infiltration or infection, such as swelling, redness, or pain. Simply looking or asking the child may miss subtle signs, and removing all the tape unnecessarily disrupts the site.
2. A patient with no known allergies is to receive penicillin every 6 hours. When administering the medication, the nurse observes a fine rash on the patient’s skin. The most appropriate nursing action would be to:
- A. Withhold the medication and notify the physician
- B. Administer the medication and notify the physician
- C. Administer the medication with an antihistamine
- D. Apply corn starch soaks to the rash
Correct answer: A
Rationale: In this scenario, the appearance of a rash after administering penicillin, even in a patient with no known allergies, is concerning for a potential allergic reaction. The appropriate action for the nurse to take is to withhold the medication and notify the physician. This precaution is necessary to prevent further administration of a medication that may be causing an adverse reaction, as allergic reactions can range from mild to severe and require immediate intervention.
3. A client with a new prescription for levothyroxine is receiving teaching from a nurse. Which statement indicates understanding of the teaching?
- A. I should take this with food
- B. I will see immediate results
- C. I might not realize the full effect of the medication for several weeks
- D. I should stop if I feel better
Correct answer: C
Rationale: The correct answer is C: 'I might not realize the full effect of the medication for several weeks.' Levothyroxine is a medication that may take several weeks for the full effect to be evident. Choice A is incorrect because levothyroxine should be taken on an empty stomach. Choice B is incorrect because immediate results are not expected with levothyroxine. Choice D is incorrect because stopping the medication without consulting a healthcare provider can be harmful, even if the client feels better.
4. Before discharge from the chemical dependency unit, clients are introduced to different community resources. Which of the following resources would be best for a teenage client, who has been abusing over-the-counter sedatives and is ready for discharge in two days?
- A. Detoxification center
- B. Home care
- C. Assertive community team
- D. Twelve-step recovery group
Correct answer: A: Detoxification center
Rationale: For a teenage client who has been abusing over-the-counter sedatives and is ready for discharge in two days, the best resource would be a detoxification center. This specialized facility can provide the necessary medical and psychological support to safely manage the withdrawal symptoms associated with substance abuse. It is crucial to ensure a safe and supervised detox process for the client's well-being and successful recovery.
5. What is the most important nursing action for a patient experiencing a deep vein thrombosis (DVT)?
- A. Administer anticoagulants
- B. Encourage ambulation
- C. Apply compression stockings
- D. Monitor oxygen saturation
Correct answer: A
Rationale: Administering anticoagulants is the most crucial nursing action for a patient experiencing a deep vein thrombosis (DVT). Anticoagulants help prevent further clot formation and reduce the risk of complications such as pulmonary embolism. Encouraging ambulation, applying compression stockings, and monitoring oxygen saturation are important interventions in managing DVT, but administering anticoagulants takes priority as it directly targets the clotting process and prevents clot progression.
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