ATI Nursing Care of Children Practice A

A nurse has just received change-of-shift report for four children in a pediatric unit. Which of the following children should the nurse collect data from first? - correct answersA child who has a fever and nuchal rigidity A client who has a fever and nuchal rigidity is unstable. This finding indicates bacterial meningitis, which requires urgent data collection and intervention to reduce complications for the child and prevent further spread of the infection. Therefore, the nurse should collect data from this child first. A nurse in a clinic is collecting data from an adolescent who has received all recommended immunizations through the age of 6 years. Which of the following immunizations should the nurse plan to administer? - correct answersTetanus, diphtheria toxoids, and acellular pertussis (Tdap) The Tdap vaccine is recommended between the ages of 11 and 12 years. Therefore, this adolescent should receive the Tdap vaccine now. A nurse in a community center is reinforcing teaching about poison control with a group of parents. A parent asks what to do if a child ingests a large quantity of acetaminophen. Identify the sequence of actions the nurse should recommend to the parent. - correct answersDetermine if the child is breathing. Empty the child's mouth of remaining pills and residue. Identify the medication and dosage strength. Call a poison control center. The child's respiratory and cardiovascular status should be checked first to determine if CPR is necessary. Then, the child's mouth should be emptied of pills and residue to prevent additional exposure to the medication. Next, the parent should identify the medication and dosage strength by looking at the medication container. Lastly, the parent should contact a poison control center for advice on the next course of action. A nurse in a pediatric clinic is collecting data from an infant who recently started taking digoxin. Which of the following manifestations should the nurse identify as an indication of digoxin toxicity and report to the provider? - correct answersVomiting The nurse should identify that vomiting, especially unrelated to feedings, is a manifestation of digoxin toxicity and should be reported to the provider. A nurse in a pediatric clinic is collecting data from an infant who was recently exposed to pertussis. The nurse should recognize which of the following as a manifestation of pertussis? - correct answersDry cough The nurse should identify that a dry cough is an early manifestation of pertussis