ATI RN
Nursing Care of Children ATI
1. The nurse is caring for a child receiving chemotherapy with the following orders: Zantac 70 mg IV in normal saline 30 mL to infuse over 30 minutes. The nurse should set the infusion pump to deliver how many mL/hour?
- A. 60 mL/hour
- B. 45 mL/hour
- C. 30 mL/hour
- D. 15 mL/hour
Correct answer: A
Rationale: The correct answer is A: 60 mL/hour. The total volume to be infused is 30 mL over 30 minutes. To calculate the infusion rate in mL/hour, divide the total volume by the total time in hours. In this case, 30 mL / 0.5 hours = 60 mL/hour. Choice B, 45 mL/hour, is incorrect as it does not correspond to the calculated infusion rate. Choices C and D, 30 mL/hour and 15 mL/hour respectively, are also incorrect based on the calculation.
2. The LPN is assessing for fontanels on the head of a 6-month-old. Which fontanel is expected to still be present?
- A. Posterior
- B. Anterior
- C. Sphenoid
- D. Lambdoid
Correct answer: B
Rationale: The correct answer is B: Anterior. The anterior fontanel usually remains open until about 12-18 months of age, while the posterior fontanel closes by 2-3 months. Choices A, C, and D are incorrect as the posterior fontanel closes by 2-3 months of age, and the sphenoid and lambdoid fontanels are not typically assessed in routine infant head examinations.
3. What clinical manifestation(s) should the nurse expect to see as shock progresses in a child and becomes decompensated shock?
- A. Thirst
- B. Irritability
- C. Apprehension
- D. Confusion and somnolence
Correct answer: D
Rationale: As shock progresses and decompensation occurs, confusion and somnolence are indicative of reduced cerebral perfusion. Early signs include thirst and irritability, while confusion and altered consciousness appear as the condition worsens.
4. The nurse is preparing to administer a measles, mumps, rubella, and varicella (MMRV) vaccine. Which is a contraindication associated with administering this vaccine?
- A. The child has recently been exposed to an infectious disease
- B. The child has symptoms of a cold but no fever
- C. The child is having intermittent episodes of diarrhea
- D. The child has a disorder that causes a deficient immune system
Correct answer: D
Rationale: A compromised immune system is a contraindication for the MMRV vaccine because it is a live attenuated vaccine and could potentially cause an infection in an immunocompromised child.
5. The nurse is preparing to perform a physical assessment on a 10-year-old girl. The nurse gives her the option of her mother staying in the room or leaving. This action should be considered which?
- A. Appropriate because of the child's age
- B. Appropriate, but the mother may be uncomfortable
- C. Inappropriate because of the child's age
- D. Inappropriate because the child is the same sex as the mother
Correct answer: A
Rationale: It is appropriate to give a 10-year-old the choice of having a parent present or not during an exam, respecting the child's growing need for privacy.
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