ATI RN
ATI Nursing Care of Children
1. The nurse is assessing a child's capillary refill time. This can be accomplished by doing what?
- A. Inspect the chest
- B. Auscultate the heart
- C. Palpate the apical pulse
- D. Palpate the nail bed with pressure to produce a slight blanching
Correct answer: D
Rationale: Capillary refill time is assessed by applying pressure to the nail bed and observing how quickly the color returns, indicating peripheral circulation status.
2. During an otoscopic examination on an infant, in which direction is the pinna pulled?
- A. Up and back
- B. Up and forward
- C. Down and back
- D. Down and forward
Correct answer: C
Rationale: For infants, the pinna is pulled down and back to straighten the ear canal and allow proper visualization of the tympanic membrane during otoscopic examination.
3. What intervention is crucial during a sickle cell crisis in a child?
- A. Administer oxygen
- B. Apply cold compresses
- C. Restrict fluids
- D. Encourage bed rest
Correct answer: A
Rationale: Administering oxygen is crucial during a sickle cell crisis in a child as it helps to prevent further sickling of cells. Oxygen therapy can improve oxygen saturation levels, reducing the risk of tissue damage and complications. Applying cold compresses (choice B) is not recommended as it can potentially worsen vaso-occlusive crisis by causing vasoconstriction. Restricting fluids (choice C) is not appropriate as hydration is essential to prevent dehydration and maintain adequate blood flow. Encouraging bed rest (choice D) may be necessary but administering oxygen takes precedence in managing a sickle cell crisis.
4. An infant is suspected of having esophageal atresia/tracheoesophageal fistula. While waiting for the pediatrician to see the infant, which action should the nurse take?
- A. Position the infant with the head of the bed slightly elevated
- B. Allow the infant to bond with the mother in her room
- C. Offer the infant breastfeeding instead of formula feeding
- D. Wrap the infant in blankets and place in a crib by the viewing window
Correct answer: A
Rationale: Positioning the infant with the head of the bed elevated helps to prevent aspiration and manage secretions until further treatment can be provided. Choice B is incorrect as the priority is ensuring the infant's safety and health, not immediate bonding. Choice C is incorrect as breastfeeding may worsen the condition. Choice D is incorrect as it does not address the potential risk of aspiration associated with esophageal atresia/tracheoesophageal fistula.
5. An 8-year-old girl asks the nurse how the blood pressure apparatus works. The most appropriate nursing action is which?
- A. Ask her why she wants to know.
- B. Determine why she is so anxious.
- C. Explain in simple terms how it works.
- D. Tell her she will see how it works as it is used.
Correct answer: C
Rationale: Providing a simple explanation satisfies the child's curiosity and helps reduce any anxiety about the procedure.
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