a nurse is caring for a toddler diagnosed with respiratory syncytial virus rsv which of the following actions should the nurse take
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment Form B

1. A nurse is caring for a toddler diagnosed with respiratory syncytial virus (RSV). Which of the following actions should the nurse take?

Correct answer: A

Rationale: Using a designated stethoscope is the correct action when caring for a toddler diagnosed with RSV. This measure helps prevent the spread of infection to other clients by reducing the risk of contamination. Wearing an N95 respirator mask is not necessary for routine care of a toddler with RSV unless performing aerosol-generating procedures. Removing the disposable gown after leaving the toddler's room is important for infection control but not specific to RSV care. Placing the toddler in a room with negative air pressure is not a standard practice for managing RSV in toddlers.

2. A nurse is providing teaching about breastfeeding to a client who is postpartum. Which of the following instructions should the nurse include?

Correct answer: C

Rationale: The correct answer is C: 'Ensure your newborn has at least six wet diapers per day.' Six or more wet diapers per day is an indicator that the newborn is receiving adequate breast milk, making this an important part of breastfeeding education. Choice A is incorrect because washing nipples with soap after each feeding can lead to dryness and cracking. Choice B is incorrect as babies should nurse on demand rather than on a strict schedule of 5 minutes every 4 hours. Choice D is incorrect as giving water to a newborn between feedings is not recommended and can interfere with breastfeeding.

3. A nurse is providing teaching for a client who has GERD. Which of the following assessment findings should the nurse expect to find?

Correct answer: C

Rationale: The correct answer is C: Atypical chest pain. GERD often presents with atypical chest pain due to acid reflux, which can mimic the symptoms of cardiac conditions but is related to the esophagus. Shortness of breath (choice A) is not a typical assessment finding in GERD. Rebound tenderness (choice B) is associated with peritoneal inflammation, not GERD. Vomiting blood (choice D) is a severe symptom that may indicate esophageal damage but is not a common assessment finding in GERD.

4. A nurse is preparing to administer a client's first dose of a new antibiotic. Which of the following is the priority nursing action?

Correct answer: A

Rationale: Assessing allergies before administering a new medication is crucial as it helps prevent potentially life-threatening allergic reactions like anaphylaxis. While monitoring vital signs and informing the client of side effects are important nursing actions, assessing allergies takes precedence to ensure the client's safety. Informed consent is necessary for the treatment process, but assessing allergies is the priority before administering any new medication.

5. A healthcare provider is reviewing the health history of an older adult who has a hip fracture. The healthcare provider should identify what as a risk factor for developing pressure injuries?

Correct answer: B

Rationale: Urinary incontinence is a significant risk factor for skin breakdown and pressure injuries. It can lead to prolonged skin exposure to moisture and irritants, increasing the susceptibility to pressure injuries. Advanced age (Choice A) is a risk factor due to changes in skin integrity and decreased tissue viability, but it is not as direct a risk factor as urinary incontinence. Regular skin assessments (Choice C) are important for early detection and prevention but are not a risk factor themselves. Adequate hydration (Choice D) is essential for overall skin health but is not a direct risk factor for pressure injuries.

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