ATI PN NURSING CARE OF CHILDREN PROCTORED EXAM VERSION 1 4. A nurse is assis ting with the ca re of a child who is postoperative and r eceived a transfu sion during a surgical procedure. Which of the following findings indicates the child is havig a hemoly tic reaction? a) Chills and flank pain (Chills and flank pain are findin gs that indic ate an incompatib ility of the transfused blood product with the client's blood. The nurse should iden tify this finding as an indication that the child is h aving a hemolytic reaction.) b) Pruri tus and flushing c) Rales and cyanosis d) Brady cardia and diarrhea 5. A guardian calls the clinic nurse after h is child has devel oped sym ptoms of varicella and asks when his childwill no longer be contagious. Which of the follo wing responses shou ld the nu rse make? a) “When your child no longer has a fever.” b) “Thr ee days after the rash started.” c) “Six days after lesions appear if they are crusted.” (The nurse should inform the guardian that a child will stop being co ntagious around 6 days a fter the lesions appe ared, as long as they are crusted over.) d) “When your child’s lesionsdisappear.” 6. A nurse is collecting date fr om a child during a well-child visit. The nurse should recog nize that which of the following findings places the child at a higher risk for abuse? a) The child is 6 years old. b) The child is male. c) The c hild w as born at 30 weeks of gestation. (The n urse sho uld identify that children who are born prematurely are at greater risk for abuse because of the potential for impaired bonding d uring early infancy.) d) The child was born via cesarean birth. 7. A nurse is reinfor cing teaching with the guardian of a child who has a new diagnosis of rheum atic fever. Which of the following sta tements by the g uardian in dicates an understand ing of the teaching? a) “Ishou ld not give my child aspirin for pain or fever. ” b) “My child will take antibiotic for 6 months.” c) “My child might h ave a period of irregular movem ent of the extremities.” (The nurse should instruct the guardian that the child might experience chorea weeks or months after the initial diagnosis. Cho rea is a temp orary lack of coordi nation and the presence of sudden, irregular mov ements or periods of clumsine ss.) d) “I should expect there to be blood in my child’s urine.” 8. A nurse is collecting data from an infant during a well-child visit. Which of the following sites should the nurse use when o btaining the infant’s heart rate? a) Apical (The nurse should use the apical pulse to obtain the infant's heart rate and count it for a full minute, because it gives a reliable rate and rhythm and provides accurate baseline assessment data. In an infant, the apical heart rate is auscultated at the fourth intercostal space lateral to the midclavicular line.) b) Radial c) Carotid d) Femoral 9. A nurse is preparing a toddler for suturing of a minor facial laceration. The nurse shou ld place the toddler in which of the following restraints? a) Mum my restraint (The nurse should use a mummy wrap when a short-term restraint is needed for treatment of the to ddler that involves the head and neck. The nurse should al ways use the least amount of restraint necessary.) b) Jacket restraint c) Elbow restraint d) Wrist restraint 10. A nurse is reinforcing dietary teaching with the parent of a 2-year-old toddler. Which of the following s hould the nurse include in the teaching? a) "It is recommended that the toddler consumes no more than 12 ounces of fruit juice each day." b) "An appropriate serving size is 1 tablespoon of food per year of age." (The n urse should include that an appropriate serving size for a 2-year-old toddler is 1 tbsp of food per year of age.) c) "Introducehealthyfinger foods like carrots and celerysticks." d) "Enco urage 5 cups of low-fat milk each day." 11. During a well-child visit, the pare nt of a toddler expresses concern to the nurse that the toddler ta kes several hours to fall asleep at night. Which of the following recommendations should the nu rse make? a) Vary the time the toddler goes to bed each night b) Allowthe toddler to watch television before bedtime c) Provide the toddler with a favori te toy at bedtime. (The nurse should recommend to the parent that prov iding the tod dler with a favorite toy at bedtime will help the toddler to feel more s ecure and fac ilitate sleep.) d) Increase the toddler's activity prior to bedtime 12. A nurse is assisting with the ca re for a 7-month-old infant who has a cleft palate. Which of the following actions should the nurse take to decrease the infant’s risk for aspiration? a) Feed the infant in supine position. b) Encou rage the mother to breastfeed the infant exclusively. c) Burp the infant frequently during feedings. (Infants with a cle ft palate have difficulty creating a seal around a bottle. Burping the infant frequently, follow ing every ounce of f luid consumed, dissipates sw allowed air and helps to preve nt aspiration.) d) Performnasotracheal suctioningif coughingoccurs
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