ATI RN
RN Nursing Care of Children Online Practice 2019 A
1. The nurse is teaching parents guidelines for feeding their 8-month-old infant with failure to thrive (FTT). Which statement by the parents indicates a need for further teaching?
- A. We will continue to use the 24-kcal/oz formula.
- B. We will be sure to follow the formula preparation instructions.
- C. We will be sure to give our infant at least 8 oz of juice every day.
- D. We will be sure to feed our infant according to the written schedule.
Correct answer: C
Rationale: Providing 8 oz of juice daily is excessive for an 8-month-old infant and can displace other nutrient-rich foods or formulas that are necessary for growth, especially in an infant with FTT.
2. The nurse is preparing a presentation on compensated, decompensated, and irreversible shock in children. What clinical manifestations related to decompensated shock should the nurse include? (Select all that apply.)
- A. All below
- B. Oliguria
- C. Confusion
- D. Pale extremities
Correct answer: A
Rationale: Decompensated shock is characterized by signs such as oliguria, confusion, pale extremities, hypotension, and a thready pulse. These indicate that the body is no longer able to maintain adequate circulation to vital organs.
3. The nurse determines that a child's intravenous infusion has infiltrated. The infused solution is a vesicant. What is the most appropriate nursing action?
- A. Stop the infusion and apply ice.
- B. End the infusion and notify the practitioner.
- C. Slow the infusion rate and notify the practitioner.
- D. Discontinue the infusion and apply warm compresses.
Correct answer: B
Rationale: If a vesicant solution infiltrates, stopping the infusion immediately and notifying the practitioner is critical to prevent tissue damage. Cold or warm compresses should only be applied following specific medical advice based on the vesicant involved.
4. Ongoing fluid losses can overwhelm the child’s ability to compensate, resulting in shock. What early clinical sign precedes shock?
- A. Tachycardia
- B. Slow respirations
- C. Warm, flushed skin
- D. Decreased blood pressure
Correct answer: A
Rationale: Tachycardia is an early sign of shock as the body tries to maintain cardiac output in the face of declining circulatory volume. Blood pressure often remains normal until late in the progression, at which point decompensated shock is occurring.
5. A child with acetaminophen (Tylenol) poisoning has been admitted to the emergency department. What antidote does the nurse anticipate being prescribed?
- A. Carnitine (Carnitor)
- B. Fomepizole (Antizol)
- C. Deferoxamine (Desferal)
- D. N-acetylcysteine (Mucomyst)
Correct answer: D
Rationale: N-acetylcysteine is the specific antidote for acetaminophen poisoning, working by replenishing glutathione and preventing liver damage. The other options are antidotes for different types of poisoning (e.g., Fomepizole for methanol or ethylene glycol poisoning).
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