NR328 Pediatric Nursing - ATI Learning System RN 3.0 Questions and Answers.
NR328 Pediatric Nursing - ATI Learning System RN 3.0 Questions and Answers.
... [Show More] (Nursing Care of Children 1)
1. A nurse in the emergency department is caring for a 2-year-old child who was found by his parents crying and holding a container of toilet bowl cleaner. The child's lips are edematous and inflamed, and he is drooling. Which of the following is the priority action by the nurse?
a. Remove the child's contaminated clothing.
b. Check the child's respiratory status.
c. Administer an antidote to the child.
d. Establish IV access for the child.
Rationale: The nurse should apply the ABC priority-setting framework when answering this item. This framework emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore the nurse’s priority concern. When applying the ABC priority setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. The nurse observes that the child’s lips are edematous and inflamed and that he is drooling. These findings indicate that the child might have swelling of the oral cavity and pharynx, which can result in a compromised airway.
2. A nurse is teaching a parent of a 12-month old child about development during the toddleryears. Which of the following statements should the nurse include?
a. "Your child should be referring to himself using the appropriate pronoun by 18 months of age."
b. "A toddler's interest in looking at pictures occurs at 20 months of age."
c. "A toddler should have daytime control of his bowel and bladder by 24 months of age."
d. "Your child should be able to scribble spontaneously using a crayon at the age of 15
months."
Rationale: The nurse should teach the parent that at the age of 15 months, the toddler should be able to scribble spontaneously, and at the age of 18 months, the toddler should be able to make strokes imitatively.
3. A nurse is caring for a toddler and is preparing to administer 0.9% sodium chloride 100 mL IV to infuse over 4 hr. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
25 gtt
Rationale: 100ml/4 hr x 60gtt/1mlx 1 hr/60min= 6000/240= 25 gtt
Ratio and Proportion
STEP 1: What is the unit of measurement to calculate? gtt/min
STEP 2: What is the volume needed? 100 mL
STEP 3: What is the total infusion time? 4 hr
STEP 4: Should the nurse convert the units of measurement? Yes (min does not equal hr)
1 hr/60 min = 4 hr/X min
X = 240 min
STEP 5: Set up an equation and solve for X.
Volume (mL)/Time (min) = drop factor (gtt/mL) = X
100 mL/240 min x 60 gtt/mL = X gtt/min
X = 25
STEP 6: Round if necessary.
STEP 7: Reassess to determine whether the amount to administer makes sense. If the prescription reads 100 ml of 0.9% sodium chloride IV to infuse over 4 hr, it makes sense to administer 25 gtt/min. The nurse should set the manual IV infusion to deliver0.9% sodium chloride IV at 25 gtt/min.
Dimensional Analysis
STEP 1: What is the unit of measurement to calculate? gtt/min
STEP 2: What is the volume needed? 100 mL
STEP 3: What is the total infusion time? 4 hr
STEP 4: Should the nurse convert the units of measurement? Yes (min does not equal hr)
STEP 5: Set up an equation and solve for X.
X = Quantity / 1 mL x Conversion (hr) / Conversion (min) x Volume (mL) / Time (hr)
X gtt/min = 60 gtt/1 mL x 1 hr/ 60 min x 100 mL/4 hr
X = 25
STEP 6: Round if necessary.
STEP 7: Reassess to determine whether the amount to administer makes sense. If the prescription reads 100 ml of 0.9% sodium chloride IV to infuse over 4 hr, it makes sense to administer 25 gtt/min. The nurse should set the manual IV infusion to deliver 0.9% sodium chloride IV at 25 gtt/min.
4. A nurse in a pediatric clinic is assessing a toddler at a well-child visit. Which of the following actions should the nurse take?
a. Perform the assessment in a head to toe sequence.
b. Minimize physical contact with the child initially.
c. Explain procedures using medical terminology.
d. Stop the assessment if the child becomes uncooperative.
Rationale: The nurse should initially minimize physical contact with the toddler, and then progress from the least traumatic to the most traumatic procedures.
5. A nurse is caring for an 18-year-old adolescent who is up-to-date on immunizations and is planning to attend college. The nurse should inform the client that he should receive which of the following immunizations prior to moving into a campus dormitory?
a. Pneumococcal polysaccharide
b. Meningococcal polysaccharide
c. Rotavirus
d. Herpes zoster
Rationale: The meningococcal polysaccharide immunization is used to prevent infection by certain groups of meningococcal bacteria. Meningococcal infection can cause life-threatening illnesses, such as meningococcal meningitis, which affects the brain, and meningococcemia, which affects the blood. Both of these conditions can be fatal. College freshmen, particularly those who live in dormitories, are at an increased risk for meningococcal disease relative to other persons their age. Therefore, the Centers for Disease Control and Prevention has issued a recommendation that all incoming college students receive the meningococcal immunization.
6. A nurse is teaching the parent of an infant about food allergens. Which of the following foods should the nurse include as being the most common food allergy in children?
a. Cow's milk
b. Wheat bread
c. Corn syrup
d. Eggs
Rationale: According to evidence-based practice, the nurse should instruct the parent that cow’s milk is the most common food allergy in children. Some children are sensitive to the protein, called casein, found in cow’s milk. They have difficulty metabolizing the casein and are, therefore, allergic to cow’s milk.
7. A nurse is teaching the parent of a toddler about home safety. Which of the following statements by the parent indicates an understanding of the teaching?
a. "I lock my medications in the medicine cabinet."
b. "I keep my child's crib mattress at the highest level."
c. "I turn pot handles to the side of my stove while cooking."
d. "I will give my child syrup of ipecac if she swallows something poisonous."
Rationale: Locking up medications and other potential poisons prevents access. Toddlers have improved gross and fine motor skills that allow for further exploration of the environment and possible access to hazardous substances.
8. A nurse is performing a physical assessment on a 6-month-old infant. Which of the following reflexes should the nurse expect to find?
a. Stepping
b. Babinski
c. Extrusion
d. Moro
Rationale: The Babinski reflex, which is elicited by stroking the bottom of the foot and causing the toes to fan and the big toe to dorsiflex, should be present until the age of 1 year. Persistence of neonatal reflexes might indicate neurological deficits. [Show Less]