which action should the nurse implement when taking an axillary temperature
Logo

Nursing Elites

ATI RN

ATI Nursing Care of Children

1. Which action should the nurse implement when taking an axillary temperature?

Correct answer: C

Rationale: The correct technique involves placing the thermometer tip in the center of the axilla to ensure an accurate reading, with the arm held close to the body.

2. The nurse is teaching a parent with a 2-month-old infant who has been diagnosed with colic about ways to relieve colic. Which statement by the parent indicates the need for additional teaching?

Correct answer: A

Rationale: Letting an infant cry for prolonged periods can exacerbate colic and increase the infant's distress. It is better to respond promptly to soothe the baby. Other methods like swaddling, gentle massage, and keeping the infant upright can help relieve colic symptoms.

3. A child has a central venous access device for intravenous (IV) fluid administration. A blood sample is needed for a complete blood count, hemogram, and electrolytes. What is the appropriate procedure to implement for this blood sample?

Correct answer: C

Rationale: Withdrawing and discarding a sample equal to the amount of fluid in the device ensures that the blood drawn is not diluted by the IV fluids, providing accurate lab results.

4. The nurse is aware that skin turgor best estimates what?

Correct answer: B

Rationale: Skin turgor is a quick and simple way to assess hydration status. Poor skin turgor can indicate dehydration.

5. When assessing a child with chronic renal failure, which clinical manifestations would the nurse expect to find?

Correct answer: A

Rationale: When assessing a child with chronic renal failure, the nurse would expect to find uremic frost as a clinical manifestation. Uremic frost, a white powdery deposit of urea on the skin, occurs in severe cases of chronic renal failure due to the accumulation of urea and other waste products in the blood. Hypotension and massive hematuria are less common in chronic renal failure, while severe metabolic acidosis is typically mild to moderate and not a prominent clinical manifestation.

Similar Questions

An infant is born with a gastroschisis. Care preoperatively should include which priority intervention?
A 4-month-old infant is discharged home after surgery for the repair of a cleft lip. What should instructions to the parents include?
A mother tells the nurse that she does not want her infant immunized because of the discomfort associated with injections. What should the nurse explain?
Which type of family should the nurse recognize when the paternal grandmother, the parents, and two minor children live together?
In addition to injuries, what are the leading causes of death in adolescents ages 15 to 19 years?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses