ATI RN
Nursing Care of Children ATI
1. The apnea monitor alarm sounds on a neonate for the third time during this shift. What is the priority action by the nurse?
- A. Provide tactile stimulation.
- B. Administer 100% oxygen.
- C. Investigate possible causes of a false alarm.
- D. Assess infant for color and presence of respirations.
Correct answer: D
Rationale: The priority action for the nurse when the apnea monitor alarm sounds on a neonate is to assess the infant for color and the presence of respirations. This initial assessment helps determine the infant's respiratory status and the need for immediate intervention. Providing tactile stimulation or administering oxygen should only be done after assessing the infant's respiratory status. Investigating possible causes of a false alarm comes after ensuring the infant's well-being through the initial assessment.
2. The nurse is evaluating research studies according to the GRADE criteria and has determined the quality of evidence on the subject is moderate. Which type of evidence does this determination indicate?
- A. Strong evidence from unbiased observational studies
- B. Evidence from randomized clinical trials showed inconsistent results
- C. Consistent evidence from well-performed randomized clinical trials
- D. Evidence for at least one critical outcome from randomized clinical trials had serious flaws
Correct answer: B
Rationale: Moderate evidence typically indicates that results from randomized clinical trials were inconsistent, highlighting the need for further research to confirm findings.
3. Which clinical manifestations should the nurse expect in a child diagnosed with nephroblastoma?
- A. Atrial fibrillation
- B. Endocarditis
- C. Hyperlipidemia
- D. Hypertension
Correct answer: D
Rationale: The correct answer is D: Hypertension. Nephroblastoma, also known as Wilms' tumor, often causes hypertension due to its impact on the kidney, which plays a role in regulating blood pressure. Atrial fibrillation (choice A) and endocarditis (choice B) are not typically associated with nephroblastoma. Hyperlipidemia (choice C) is also not a common clinical manifestation of nephroblastoma.
4. The nurse is preparing to complete documentation on a patient's chart. Which should be included in documentation of nursing care? (Select all that apply.)
- A. Reassessments
- B. Nursing care provided
- C. Initial assessments
- D. All of the above
Correct answer: D
Rationale: Proper documentation includes reassessments, initial assessments, care provided, and the patient's response, but incident reports are typically documented separately.
5. What is the primary concern in a child with nephrotic syndrome?
- A. Hypotension
- B. Hyperkalemia
- C. Hyperlipidemia
- D. Hypocalcemia
Correct answer: C
Rationale: The correct answer is C: Hyperlipidemia. Children with nephrotic syndrome often present with hyperlipidemia due to altered lipid metabolism, making it a primary concern in these patients. Hypotension (choice A) is not a primary concern in nephrotic syndrome. Hyperkalemia (choice B) and hypocalcemia (choice D) are not typically associated with nephrotic syndrome and are less likely to be primary concerns in these patients.
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