ATI RN
ATI Nursing Care of Children 2019 B
1. What is the first step in treating a child with suspected anaphylaxis?
- A. Administer oxygen
- B. Start an IV line
- C. Give epinephrine
- D. Monitor vital signs
Correct answer: C
Rationale: The correct answer is C: Give epinephrine. Administering epinephrine is the first and most critical step in treating anaphylaxis. Epinephrine rapidly reverses the symptoms of anaphylaxis, including airway swelling, hypotension, and shock. Delaying administration can lead to severe complications or death, making it essential in emergency treatment. Choice A, administering oxygen, might be necessary but should not delay the administration of epinephrine. Starting an IV line (Choice B) is important for further treatment but not the initial step. Monitoring vital signs (Choice D) is essential but comes after administering epinephrine to stabilize the child.
2. An infant is born with a gastroschisis. Care preoperatively should include which priority intervention?
- A. Prone position
- B. Sterile water feedings
- C. Monitoring serum laboratory electrolytes
- D. Covering the defect with a sterile bowel bag
Correct answer: D
Rationale: The correct priority intervention for an infant with gastroschisis is to cover the exposed abdominal contents with a sterile bowel bag. This action helps protect the intestines from injury, contamination, and dehydration before surgical repair. Choice A, placing the infant in the prone position, is not appropriate as it does not address the immediate need to protect the exposed intestines. Choice B, sterile water feedings, and Choice C, monitoring serum laboratory electrolytes, are not the priority interventions for this condition. Sterile water feedings may not provide the necessary protection for the exposed intestines, and monitoring electrolytes, while important, is secondary to the immediate need for protection and hydration of the exposed abdominal contents.
3. Which are included in the evaluation step of the nursing process? (Select all that apply.)
- A. All below
- B. Ascertaining if the plan requires modification
- C. Determination if the outcome has been met
- D. Selecting alternative interventions if the outcome has not been met
Correct answer: A
Rationale: The evaluation step involves determining if outcomes are met, modifying the plan if needed, and selecting alternative interventions if goals are not achieved.
4. A two-month-old infant who has gastroesophageal reflux is thriving without other complications. Which instruction should the nurse include in the teaching plan?
- A. Place the infant in the Trendelenburg position after feeding
- B. Thicken formula with rice cereal
- C. Give continuous nasogastric feedings
- D. Give larger, less frequent feeds
Correct answer: B
Rationale: The correct instruction for a two-month-old infant with gastroesophageal reflux who is thriving without complications is to thicken the formula with rice cereal. This can help reduce reflux by increasing the weight of the formula, making it less likely to be regurgitated. Placing the infant in the Trendelenburg position after feeding (Choice A) is not recommended as it can increase the risk of aspiration. Continuous nasogastric feedings (Choice C) are not typically indicated for uncomplicated reflux in infants. Giving larger, less frequent feeds (Choice D) can worsen reflux symptoms by overloading the stomach.
5. What is the most common piece of medical equipment that can transmit harmful microorganisms among patients?
- A. Thermometer
- B. Stethoscope
- C. Injection needle
- D. Disposable gloves
Correct answer: B
Rationale: The correct answer is B: Stethoscope. A stethoscope is commonly used between patients, and if not correctly disinfected, it can be a dangerous source of spreading microorganisms. Thermometers typically have barriers to prevent this type of transmission. Injection needles are discarded immediately after use and not reused, making them an unlikely source of transmission. Similarly, disposable gloves are not reused, so they are also not a common source of harmful microorganism transmission.
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