a nurse is assessing an infant who has pneumonia which of the following findings is the priority for the nurse to report to the provider
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Nursing Elites

ATI RN

RN Pediatric Nursing 2023 ATI

1. During an assessment, a healthcare professional is evaluating an infant with pneumonia. Which of the following findings should be the priority for the healthcare professional to report to the provider?

Correct answer: A

Rationale: When assessing an infant with pneumonia, the priority finding to report to the provider is nasal flaring. Nasal flaring indicates acute respiratory distress, which can be a life-threatening condition requiring immediate intervention. Monitoring and addressing respiratory distress take precedence over other symptoms or laboratory results in this situation.

2. A child is being assessed for Kawasaki disease. Which of the following findings should be expected?

Correct answer: C

Rationale: In Kawasaki disease, a child typically presents with a fever that is unresponsive to antipyretics because the disease is characterized by systemic inflammation. The persistent fever is a hallmark feature of the disease and can last for more than five days despite treatment with antipyretics.

3. While auscultating the lungs of an adolescent with asthma, what should the nurse identify the sound as?

Correct answer: C

Rationale: The nurse should identify the sound heard during auscultation as tachypnea, which is characterized by a rapid, regular breathing pattern. In the case of an adolescent with asthma, tachypnea can be indicative of increased work of breathing due to airway constriction and inflammation. Biots respiration (choice A) is characterized by an irregular pattern of breathing with periods of apnea. Chaney-Stokes respiration (choice B) is a pattern of breathing characterized by alternating periods of deep, rapid breathing followed by periods of apnea. Bradypnea (choice D) refers to an abnormally slow breathing rate, which is not typically associated with asthma exacerbation.

4. A preschool-age child is admitted to the hospital with acute postinfectious glomerulonephritis (APIGN). Which is the priority nursing diagnosis for this child?

Correct answer: A

Rationale: The priority nursing diagnosis for a preschool-age child with acute postinfectious glomerulonephritis (APIGN) is 'Risk for Injury related to hypertension' due to the potential complications such as hypertensive encephalopathy. Hypertension poses an immediate threat to the child's well-being, making it crucial to address the risk for injury associated with elevated blood pressure as the top priority.

5. The patient taking spironolactone (Aldactone) makes a statement indicating effective teaching. Which statement shows understanding of the teaching?

Correct answer: C

Rationale: The correct answer is C because spironolactone is a potassium-sparing diuretic that can cause endocrine effects like menstrual irregularities. Therefore, the patient recognizing the need to report such changes indicates effective teaching. Choices A and B are incorrect as salt substitutes and high-potassium foods should be avoided with spironolactone. Choice D is also incorrect because diuretics, including spironolactone, are ideally taken in the morning to prevent disturbances in sleep due to nocturia.

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