which assessment finding would necessitate action by the nurse for a 10 month old child who is 4 hours postoperative for the placement of a urethral s

ATI RN

RN Pediatric Nursing 2023 ATI

1. Which assessment finding would necessitate action by the nurse for a 10-month-old child who is 4 hours postoperative for the placement of a urethral stent?

A. Bloody urine
B. One void since returning from surgery
C. Bladder spasms responding to pharmacologic intervention
D. Double diapering from the previous shift

Correct answer: B

Rationale: In a postoperative scenario after the placement of a urethral stent, monitoring the child's voiding frequency is crucial. Having only one void since returning from surgery could indicate potential issues like urinary retention, which necessitates prompt nursing intervention to prevent complications.

2. During a well-child visit, a nurse is assessing a three-year-old toddler. Which of the following manifestations should the nurse report to the provider?

A. Blood pressure 90/50
B. Respiratory rate 45/min
C. Weight 14.5 kg or 32 lb
D. Heart rate 110/min

Correct answer: B

Rationale: A respiratory rate of 45/min is above the expected reference range for a 3-year-old toddler and may indicate respiratory dysfunction or acute respiratory distress. It is essential for the nurse to report this finding promptly to the healthcare provider for further evaluation and intervention.

3. Which statement by an 18-year-old woman vaccinated with Gardasil indicates that more teaching is necessary?

A. This vaccination will cure the HPV infection I got when I was 16.
B. I will still need to have a routine Pap screen performed.
C. Gardasil can prevent genital warts in males and females.
D. This drug does not protect against all types of HPV.

Correct answer: A

Rationale: The correct answer is A because Gardasil does not cure existing HPV infections. Gardasil is a preventive vaccine and does not treat existing infections. Choice B is correct as regular Pap screenings are still necessary even after vaccination. Choice C is also correct as Gardasil can prevent genital warts. Choice D is correct as Gardasil does not protect against all types of HPV. Therefore, option A is the statement that indicates the need for more teaching.

4. Why is the specific gravity for infants lower than for older children?

A. Infants have a greater body surface area.
B. Infants have a higher basal metabolic rate.
C. Infants have a greater percentage of body weight that is water.
D. Infants' kidneys are less able to concentrate urine.

Correct answer: D

Rationale: The correct answer is D because infants' kidneys are less developed compared to older children, making them less efficient at concentrating urine. This results in a lower specific gravity in infants. The other choices do not directly explain why the specific gravity is lower in infants.

5. Which statement fosters cultural competence?

A. Treat everyone the same regardless of their culture
B. Provide an outline of your beliefs as a starting point
C. Acknowledge and respond to influences of cultural beliefs in the intervention plan
D. Ask the family to outline how their beliefs will influence therapy

Correct answer: C

Rationale: Cultural competence involves recognizing and considering the impact of cultural beliefs on individuals. By acknowledging and responding to these cultural influences in the intervention plan, professionals can tailor their approach effectively and respectfully. This approach helps build trust, enhances communication, and improves outcomes in culturally diverse settings.