ATI RN
ATI Nursing Care of Children
1. With the National Center for Health Statistics criteria, which body mass index (BMI)-for-age percentiles should indicate the patient is at risk for being overweight?
- A. 10th percentile
- B. 75th percentile
- C. 85th percentile
- D. 95th percentile
Correct answer: C
Rationale: A BMI-for-age at the 85th percentile indicates a child is at risk for being overweight, according to the National Center for Health Statistics criteria.
2. A nurse is preparing medications for a client via nasogastric tube. What should the nurse do before administering the medications?
- A. Flush the tube with water and administer all medications at once
- B. Administer medications one after the other without flushing
- C. Crush all medications and mix them together for administration
- D. Administer medications in liquid form only
Correct answer: B
Rationale: Before administering medications through a nasogastric tube, the nurse should administer them one after the other without flushing. Flushing the tube with water should be done before and after each medication to prevent any interactions and ensure each medication is delivered effectively. The correct answer is not to administer all medications at once (choice A) as this can lead to potential drug interactions. Crushing all medications and mixing them together (choice C) is incorrect as each medication should be given separately to maintain their individual efficacy. Administering medications in liquid form only (choice D) is limiting and may not be suitable for all types of medications that need to be administered.
3. The nurse is preparing to administer a daily dose of digoxin. What is the priority nursing intervention?
- A. Analyze HR and rhythm
- B. Assess for Homan�s sign
- C. Check BP
- D. Palpate the pedal pulses
Correct answer: A
Rationale: Before giving digoxin, the nurse will assess the HR and rhythm. The dosage will be held and the prescriber notified if the HR is below 60 bpm or if the cardiac rhythm has changes. Digoxin can cause bradycardia and electrical changes in the heart.
4. What should you monitor when administering Clopidogrel to a patient?
- A. Signs of thrombotic thrombocytopenic purpura
- B. Bleeding during therapy
- C. CBC with differential and platelet count
- D. All of the above
Correct answer: D
Rationale: When administering Clopidogrel, it is crucial to monitor for signs of thrombotic thrombocytopenic purpura, bleeding during therapy, and changes in CBC with differential and platelet count. Thrombotic thrombocytopenic purpura is a rare but serious condition associated with Clopidogrel use, characterized by microangiopathic hemolytic anemia, thrombocytopenia, neurological symptoms, fever, and renal dysfunction. Monitoring for signs of thrombotic thrombocytopenic purpura is essential to detect this potentially life-threatening condition early. Monitoring for bleeding helps to assess the risk of hemorrhagic events, a known side effect of Clopidogrel. Additionally, regular monitoring of CBC with differential and platelet count is necessary to evaluate the drug's impact on blood cell counts and detect any abnormalities that may require intervention. Therefore, monitoring all these parameters is vital to ensure patient safety and appropriate management during Clopidogrel therapy.
5. A nurse is assessing a client who is receiving furosemide for heart failure. Which of the following findings is the priority to report to the provider?
- A. Blood pressure of 98/58 mm Hg
- B. Urine output of 50 mL/hr
- C. Serum potassium level of 3.2 mEq/L
- D. Weight loss of 0.5 kg (1.1 lb) in 24 hours
Correct answer: C
Rationale: The correct answer is C. A serum potassium level of 3.2 mEq/L indicates hypokalemia, a potential complication of furosemide therapy, and should be reported immediately. Hypokalemia can lead to serious cardiac dysrhythmias. Choices A, B, and D are important assessments but are not as critical as managing serum potassium levels in a client receiving furosemide for heart failure.
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