ATI Peds: Learning System RN 3.0 Nursing Care of Children Exam 2, Questions & Answers

ATI Peds: Learning System RN 3.0 Nursing Care of Children Exam 2, Questions & Answers-A nurse in an emergency department is caring for a 4-year-old child who has burns to the neck and face following a house fire. Which of the following actions should the nurse take first? Cover the child's wounds with a clean, dry cloth. Establish IV access for the child with a large-bore catheter. Provide reassurance to the child's parents. Determine the child's breathing pattern. - Determine the child's breathing pattern. The nurse should apply the ABC priority setting framework. 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. Determining the child's breathing pattern is the first action the nurse should take. 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. A nurse is providing teaching to the parent of a 2-year-old toddler about nutrition. Which of the following statements by the parent indicates an understanding of the teaching? "My child should consume 1,000 calories per day." "My child should have 4 ounces of protein per day." "I should give my child 32 ounces (4 cups) of milk per day." "I should feed my child 4 ounces (1/2 cup) of vegetables per day." - "My child should consume 1,000 calories per day." Toddlers who are 2 years old should consume 1,000 calories daily. A nurse is providing discharge teaching to the parent of a school-age child who has leukemia and is receiving chemotherapy. Which of the following statements by the parent indicates an understanding of the teaching? "I will take my child's rectal temperature daily." "I will make sure my child gets his MMR vaccine this week." "I will inspect my child's mouth every day for sores." "I will allow my child to ride his bicycle tomorrow." - "I will inspect my child's mouth every day for sores." A child who has leukemia is at an increased risk for mucositis; therefore, the parent should inspect the child's mouth daily for lesions or ulcerations. A nurse is preparing to obtain an antistreptolysin O (ASO) titer from a child who has acute glomerulonephritis. The child's parent asks the nurse to explain the purpose of the test. Which of the following responses should the nurse make? "The test determines the level of antibiotics in your child's blood." "The test tells us if your child ever had the measles." "The test verifies the amount of albumin in your child's blood." "The test shows us if your child had a recent strep infection." - "The test shows us if your child had a recent strep infection." An ASO titer indicates that the child has had a recent strep infection. In determining a definitive diagnosis for acute glomerulonephritis, this must be documented as it is usually the result of this type of infection. A nurse is providing nutritional teaching to an adolescent client who has celiac disease. Which of the following breakfast foods should the nurse recommend? Plain flour pastry Wheat cereal Scrambled eggs Rye toast - Scrambled eggs The client who has celiac disease should be on a low-gluten diet and should avoid foods containing barley, oat, rye, and wheat; therefore, scrambled eggs are an appropriate breakfast item for the nurse to recommend to the client. A nurse is providing teaching to an adolescent who has scoliosis and a new prescription for a Boston brace. Which of the following responses by the adolescent indicates an understanding of the teaching? "I can take my brace off to sleep every night at bedtime." "I can take my brace off for about an hour daily to shower." "I should loosen the straps on my brace if it is rubbing my skin." "I should place the pads of brace against my skin with a t-shirt over them." - "I can take my brace off for about an hour daily to shower." The nurse should instruct the child to wear the brace for 23 hr each day and to only remove it for showering or participating in physical therapy. A nurse is assessing a toddler who has measles (rubeola). Which of the following findings should the nurse expect? Koplik spots Parotitis Strawberry tongue Paroxysmal cough - Koplik spots Koplik spots are small, irregular oral lesions with a bluish-white center and are characteristic of measles (rubeola). Koplik spots appear about 2 days before the maculopapular rash appears and are accompanied by manifestations of fever, malaise, conjunctivitis, and other cold manifestations. A nurse is providing dietary teaching to the parent of a child who has cystic fibrosis. Which of the following dietary recommendations should the nurse make? Increase the child's protein intake. Decrease the child's calorie intake. Increase the child's fiber intake. Decrease the child's salt intake. - Increase the child's protein intake. The nurse should recommend an increase in protein intake for the child who has cystic fibrosis. These children require up to 150% of the recommended daily allowances to meet their nutritional needs. A nurse is admitting a child who has Wilms' tumor. Which of the following actions should the nurse take? Initiate contact precautions for the child. Explain to the parents that chemotherapy will start 3 months following surgery. Put a "no abdominal palpation" sign over the child's bed. Prepare the child for a spinal tap. - Put a "no abdominal palpation" sign over the child's bed. The nurse should place a sign over the child's bed reading "no abdominal palpation" because palpation is not necessary to confirm diagnosis and could aid in metastasis. Wilm's tumor is the most common form of kidney cancer for young children around 3-4ish A nurse is caring for an infant following surgical repair of a cleft lip and palate. Which of the following actions should the nurse take? Keep the infant's mouth open by using a tongue blade for 4 hr following surgery. Suction the infant gently with a bulb syringe PRN. Place the infant in prone position. Clean the infant's incision with chlorhexidine. - Suction the infant gently with a bulb syringe PRN.