ATI PN Nursing Care of Children 2024
Practice B
A nurse is collecting data for an adolescent who has asthma and has received an albuterol
nebulizer treatment. Which of the following findings indicates an improvement in the
adolescent's condition?
a. Temperature 38.1° C (100.5° F)
b. SaO2 91%
c. Respiratory rate 20/min
d. Bilateral wheezing - ANSRespiratory rate 20/min
Rationale: The nurse should recognize that a respiratory rate of 20/min is within the expected
reference range and indicates an improvement in the adolescent's condition.
A nurse is caring for a 1-month-old infant who has a nasogastric tube in place for intermittent
feedings. Which of the following actions should the nurse take?
a. Position the head of the crib at a 30° angle between feedings.
b. Administer feedings over 5 min.
c. Flush the tube with 30 mL of tap water.
d. Place the infant on the left side after a feeding. - ANSPosition the head of the crib at a 30°
angle between feedings.
Rationale: The nurse should place the infant with the head of the crib elevated 30° to 45° to
prevent aspiration.
A nurse in a provider's office is caring for a preschooler who has findings of croup. Which of the
following statements by the parent requires immediate intervention by the nurse?
a. "My child has been coughing throughout the night."
b. "My child is very hoarse and has a fever of 100.4 degrees Fahrenheit."
c. "My child has refused to drink any fluids for the past 8 hours."
d. "My child recently had the flu." - ANS"My child has refused to drink any fluids for the past 8
hours."
Rationale: An inadequate fluid intake indicates the child is at greatest risk for dehydration and
electrolyte imbalance. Therefore, this statement by the parent requires immediate intervention
by the nurse.
, A nurse is reinforcing discharge teaching with the guardians of a 6-month-old infant following a
surgical procedure to repair a hypospadias. Which of the following instructions should the nurse
include?
a. Avoid giving the infant fruit juice.
b. Apply anti-fungal ointment to the infant's penis.
c. Wait 1 week before giving the infant a tub bath.
d. Apply dry gauze dressing to the infant's penis twice daily. - ANSWait 1 week before giving the
infant a tub bath.
Rationale: The nurse should instruct the guardians to keep the infant's penis as dry as possible
until the stent or catheter is removed. The parent should provide sponge-baths to the child until
the stent or catheter is removed.
A nurse is collecting data from an 18-month-old toddler who has just presented to the urgent
care clinic. Which of the following data should the nurse investigate further?
a. Heart rate 110/min
b. Rectal temperature 37.4° C (99.3° F)
c. Blood pressure 120/80 mm Hg
d. Respiratory rate 25/min - ANSBlood pressure 120/80 mm Hg
Rationale: A blood pressure of 120/80 mm Hg is outside the expected reference range for an
18-month-old toddler and requires further investigation by the nurse.
A nurse is reinforcing teaching about home care with the guardian of a 14-month-old toddler
who has spastic cerebral palsy. Which of the following statements by the guardian indicates an
understanding of the teaching?
a. "I will perform daily stretching exercises to my toddler's affected muscles."
b. "I will ensure my toddler avoids activities that involve repetitive joint movements."
c. "I will place my toddler on his stomach to nap after meals."
d. "I will give my toddler pain medication just after he performs strenuous activities." - ANS"I will
perform daily stretching exercises to my toddler's affected muscles."
Rationale: The nurse should reinforce that performing stretching exercises of the toddler's
affected muscles will prevent muscle contractures.
A nurse is reinforcing teaching with the guardian of a child who has a new diagnosis of
rheumatic fever. Which of the following statements by the guardian indicates an understanding
of the teaching?
a. "My child might have a period of irregular movement of the extremities."
b. "My child will take antibiotics for 6 months."
Practice B
A nurse is collecting data for an adolescent who has asthma and has received an albuterol
nebulizer treatment. Which of the following findings indicates an improvement in the
adolescent's condition?
a. Temperature 38.1° C (100.5° F)
b. SaO2 91%
c. Respiratory rate 20/min
d. Bilateral wheezing - ANSRespiratory rate 20/min
Rationale: The nurse should recognize that a respiratory rate of 20/min is within the expected
reference range and indicates an improvement in the adolescent's condition.
A nurse is caring for a 1-month-old infant who has a nasogastric tube in place for intermittent
feedings. Which of the following actions should the nurse take?
a. Position the head of the crib at a 30° angle between feedings.
b. Administer feedings over 5 min.
c. Flush the tube with 30 mL of tap water.
d. Place the infant on the left side after a feeding. - ANSPosition the head of the crib at a 30°
angle between feedings.
Rationale: The nurse should place the infant with the head of the crib elevated 30° to 45° to
prevent aspiration.
A nurse in a provider's office is caring for a preschooler who has findings of croup. Which of the
following statements by the parent requires immediate intervention by the nurse?
a. "My child has been coughing throughout the night."
b. "My child is very hoarse and has a fever of 100.4 degrees Fahrenheit."
c. "My child has refused to drink any fluids for the past 8 hours."
d. "My child recently had the flu." - ANS"My child has refused to drink any fluids for the past 8
hours."
Rationale: An inadequate fluid intake indicates the child is at greatest risk for dehydration and
electrolyte imbalance. Therefore, this statement by the parent requires immediate intervention
by the nurse.
, A nurse is reinforcing discharge teaching with the guardians of a 6-month-old infant following a
surgical procedure to repair a hypospadias. Which of the following instructions should the nurse
include?
a. Avoid giving the infant fruit juice.
b. Apply anti-fungal ointment to the infant's penis.
c. Wait 1 week before giving the infant a tub bath.
d. Apply dry gauze dressing to the infant's penis twice daily. - ANSWait 1 week before giving the
infant a tub bath.
Rationale: The nurse should instruct the guardians to keep the infant's penis as dry as possible
until the stent or catheter is removed. The parent should provide sponge-baths to the child until
the stent or catheter is removed.
A nurse is collecting data from an 18-month-old toddler who has just presented to the urgent
care clinic. Which of the following data should the nurse investigate further?
a. Heart rate 110/min
b. Rectal temperature 37.4° C (99.3° F)
c. Blood pressure 120/80 mm Hg
d. Respiratory rate 25/min - ANSBlood pressure 120/80 mm Hg
Rationale: A blood pressure of 120/80 mm Hg is outside the expected reference range for an
18-month-old toddler and requires further investigation by the nurse.
A nurse is reinforcing teaching about home care with the guardian of a 14-month-old toddler
who has spastic cerebral palsy. Which of the following statements by the guardian indicates an
understanding of the teaching?
a. "I will perform daily stretching exercises to my toddler's affected muscles."
b. "I will ensure my toddler avoids activities that involve repetitive joint movements."
c. "I will place my toddler on his stomach to nap after meals."
d. "I will give my toddler pain medication just after he performs strenuous activities." - ANS"I will
perform daily stretching exercises to my toddler's affected muscles."
Rationale: The nurse should reinforce that performing stretching exercises of the toddler's
affected muscles will prevent muscle contractures.
A nurse is reinforcing teaching with the guardian of a child who has a new diagnosis of
rheumatic fever. Which of the following statements by the guardian indicates an understanding
of the teaching?
a. "My child might have a period of irregular movement of the extremities."
b. "My child will take antibiotics for 6 months."
