ATI RN
RN Nursing Care of Children 2019 With NGN
1. Which finding suggests fluid volume deficit in an infant presenting with vomiting and diarrhea for 2 days?
- A. Increased blood pressure
- B. A sunken fontanel
- C. Decreased pulse rate
- D. Low urine specific gravity
Correct answer: B
Rationale: A sunken fontanel is a classic sign of dehydration in infants, indicating a fluid volume deficit. In dehydration, the fontanel sinks due to decreased fluid volume in the body. Increased blood pressure (Choice A) is not typically associated with dehydration in infants. Decreased pulse rate (Choice C) is not a common finding in fluid volume deficit, as the body tries to increase the heart rate to compensate for decreased volume. Low urine specific gravity (Choice D) may be seen in dehydration, but it is not as specific or as easily observable as a sunken fontanel.
2. A nurse is providing discharge teaching to a client who has a new prescription for enoxaparin. Which of the following instructions should the nurse include?
- A. Avoid eating spinach while taking this medication.
- B. Massage the injection site after administration.
- C. Administer the injection into the deltoid muscle.
- D. Inject the medication into the abdomen.
Correct answer: D
Rationale: The correct answer is to inject the medication into the abdomen. Enoxaparin should be administered subcutaneously into the abdomen for optimal absorption. Choice A is incorrect as there is no specific interaction between enoxaparin and spinach. Choice B is incorrect as massaging the injection site after administration is not recommended and can increase bruising. Choice C is incorrect as enoxaparin injections should not be administered into the deltoid muscle.
3. The nurse assesses a wound with exudate. What should not be included when documenting the exudate?
- A. Amount
- B. Consistency
- C. Heat
- D. Odor
Correct answer: Heat
Rationale:
4. A nurse in a pediatric clinic is reviewing the laboratory test results of a school-age child. Which of the following findings should the nurse report to the provider?
- A. Hgb 12.5 g/dL.
- B. Platelets 250,000/mm³.
- C. Hct 40%.
- D. WBC 14,000/mm³.
Correct answer: D
Rationale: The correct answer is D. A WBC count of 14,000/mm³ is elevated, indicating a potential infection or inflammation, and should be reported to the provider for further evaluation and management. Choices A, B, and C are within normal ranges and do not require immediate reporting as they indicate normal hemoglobin, platelet count, and hematocrit levels for a school-age child.
5. Gina, A client in prolong labor said she cannot go on anymore. The health care team decided that both the child and the mother cannot anymore endure the process. The baby is premature and has a little chance of surviving. Caesarian section is not possible because Gina already lost enough blood during labor and additional losses would tend to be fatal. The husband decided that Gina should survive and gave his consent to terminate the fetus. The principle that will be used by the health care team is:
- A. Beneficence
- B. Non malfeasance
- C. Justice
- D. Double effect
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.