ATI RN Pediatric Nursing Online Practice 2024 A with Rationales

A nurse in an emergency department is caring for a school-age child who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse? - Administer epinephrine IM Rationale: When using the urgent vs. non-urgent approach to client care, the nurse should determine that the priority action is administering epinephrine IM to the child. During an anaphylactic reaction, histamine release causes bronchoconstriction and vasodilation. This is an emergency because ultimately it causes decreased blood return to the heart. A nurse in a pediatric emergency department is planning care for an adolescent. Based on the information in the adolescent's medical record, which of the following actions should the nurse plan to take? Select all that apply. - Apply supplemental oxygen Rationale: According to the medical record and chest x-ray report, the adolescent could potentially have a pneumothorax. Also according to the medical record and chest x-ray report, the adolescent's oxygen saturation level is decreasing, which indicates hypoxia. Therefore, the nurse should plan to administer supplemental oxygen. Prepare for chest tube insertion Rationale: According to the medical record and chest x-ray report, the adolescent could potentially have a pneumothorax. A pneumothorax is the presence of air in the pleural cavity, which results in decreased lung expansion. The adolescent couldexperience dyspnea, tachypnea, tachycardia, hypoxia, and pain. This requires prompt intervention by the provider, such as the placement of a chest tube into the thoracic cavity to remove air and fluid from the pleural space, if present, allowing the lung to re-expand. A nurse in an emergency department is caring for a school-age child who has epiglottitis. Which of the following actions should the nurse take? - Monitor the child's oxygen saturation Rationale: The nurse should monitor the child's oxygen saturation level because the child is experiencing acute respiratory distress and it is necessary to determine if the child is responding to treatment. A nurse is providing teaching about play activities for social development to the guardians of a preschooler. Which of the following play activities should the nurse recommend for the child? - Playing dress-up Rationale: The nurse should instruct the guardians that at the preschool age, play should focus on social, mental, and physical development. Therefore, playing dress-up is a recommended play activity for this child. A nurse is receiving change-of-shift report for four children. Which of the following children should the nurse see first? - A school-age child who has sickle cell anemia and reports decreased vision in the left eye Rationale: When using the urgent vs. non-urgent approach to client care, the nurse should determine the priority finding is a report of decreased vision in the left eye. This finding indicates that the child is experiencing a vaso-occlusive crisis andshould be reported to the provider immediately. Therefore, the nurse should see this child first. A nurse is providing teaching to the parents of a preschooler who has heart failure and a new prescription for digoxin twice daily. Which of the following instructions should the nurse include in the teaching? - "Brush the child's teeth after giving the medication." Rationale: The nurse should instruct the parents to brush the child's teeth after administering digoxin to prevent tooth decay caused by the medication, which comes as a sweetened liquid to enhance the taste. A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse should instruct the parent to apply which of the following to the affected area? - Zinc oxide Rationale: Diaper dermatitis is a common inflammatory skin disorder caused by contact with an irritant such as urine, feces, soap, or friction, and takes the form of scaling, blisters, or papules with erythema. Providing a protective barrier, such as zinc oxide, against the irritants allows the skin to heal. A nurse is caring for a client who has been receiving IV fluids via a peripheral IV catheter. When preparing to discontinue the IV fluids and catheter, which of the following actions should the nurse plan to take? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) - First, the nurse should turn off the IV pump. Next, the nurse should occlude the IV tubing, and then remove the tape securing the catheter. Last, the nurse should apply pressure over the catheter insertion site.A nurse is assessing a school-age child who has an acute spinal cord injury following a sports injury 1 week ago. Identify the area the nurse should tap to elicit the biceps reflex. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.) - A A nurse is caring for a school-age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take? - Screen the child's visitors for indications of infection. Rationale: A child who is severely immunocompromised is unable to adequately respond to infectious organisms, resulting in the potential for overwhelming infection. Therefore, the nurse should screen the child's visitors for indications of infection.