ATI PN NURSING CARE OF CHILDREN EXAM
SCRIPT 2026 FULL QUESTIONS AND CORRECT
ANSWERS AUTHENTIC FILE
▶ A client presents with a pressure ulcer on the ankle. Which is the first intervention
that the nurse implements?
A) Place the client in bed and instruct him or her to elevate the foot.
B) Prepare for and assist with obtaining a wound culture.
C) Assess the affected leg for pulses, skin color, and temperature.
D) Draw blood for albumin, prealbumin, and total protein. Answer: C
A client with an ulcer on the foot should be assessed for interruption in arterial flow to
the area. This begins with assessment of pulses and color and temperature of the skin.
The nurse can also assess for pulses noninvasively with a Doppler if unable to palpate
with his or her fingers. Elevation of the foot would impair the ability of arterial blood to
flow to the area. Wound cultures are done after it has been determined drainage, odor,
and other risks for infection are present. Tests to determine nutritional status and risk
assessment would be completed after the initial assessment is done.
▶ During assessment of a client with a 15-year history of diabetes, the nurse notes that
the client has decreased tactile sensation in both feet. Which action does the nurse take
first?
A) Notify the health care provider.
B) Document the finding in the client's chart.
C) Examine the client's feet for signs of injury.
D) Test sensory perception in the client's hands. Answer: C
Diabetic neuropathy is common when the disease is of long duration. The client is at
great risk for injury in any area with decreased sensation because he or she is less able
to feel injurious events. Feet are common locations for neuropathy and injury, so the
nurse should inspect them for any signs of injury. After assessing, the nurse should
document findings in the client's chart. Testing sensory perception in the hands may or
may not be needed. The health care provider can be notified after assessment and
documentation have been completed.
▶ Which nursing intervention best assists a bedridden client to keep skin intact?
A) Use a lift sheet to move the client in bed.
B) Turn the client every 2 to 4 hours.
C) Use a foam mattress pad.
D) Apply talcum powder to the perineal area. Answer: A
,Friction forces are generated when the client is dragged or pulled across bed linen; this
often leads to altered skin integrity. Using a lift sheet will prevent friction. Keeping the
skin clean and dry is an important intervention, but powders should not be used in the
perineal area. To minimize vasoconstriction and possible pressure ulcer development
from dependency, the client should be turned at a minimum of every 2 hours. A foam
mattress will not significantly decrease pressure to an area.
▶ A client presents with an acute exacerbation of multiple sclerosis. Which prescribed
medication does the nurse prepare to administer?
A) Interferon beta-1b (Betaseron)
B) Baclofen (Lioresal)
C) Methylprednisolone (Medrol)
D) Dantrolene sodium (Dantrium) Answer: C
Methylprednisolone is the drug of choice for acute exacerbations of the disease. The
other medications are not appropriate.
▶ The nurse is assessing a client's understanding of his hypertension therapy. What
client statement indicates a need for further teaching?
A) "When my blood pressure is normal, I will no longer need to take medication."
B) "If my blood pressure stays under control, I will reduce my risk for a heart attack."
C) "If I lose weight, I might be able to reduce my blood pressure medication."
D) "When getting out of bed in the morning, I will sit for a few moments then stand."
Answer: A
Compliance with antihypertensive therapy is difficult for two reasons. First, often clients
have no distressing symptoms associated with hypertension and may not believe that
they have a problem. Second, many clients believe that once blood pressure is brought
back into the normal range, they are "cured" and no longer need to take medication.
Losing weight might allow the client to reduce medications. Lowering blood pressure
does lower risk for heart attack. Because blood pressure medications often lead to
orthostatic hypotension, clients should be taught to change position slowly, sitting first
before standing after lying flat.
▶ Which of the following would be included in the assessment of a patient with diabetes
mellitus who is experiencing a hypoglycemic reaction? (Select all that apply.)
A) Constricted pupils
B) Flushed skin
C) Tremors
D) Nervousness
E) Extreme thirst
F) Profuse perspiration Answer: C,D,F
,When hypoglycemia occurs, blood glucose levels fall, resulting in sympathetic nervous
system responses such as tremors, nervousness, and profuse perspiration. Dilated
pupils would also occur, not constricted pupils. Extreme thirst, flushed skin, and
constricted pupils are consistent with hyperglycemia.
▶ A client who has had a stroke with left-sided hemiparesis has been referred to a
rehabilitation center. The client asks, "Why do I need rehabilitation?" How does the
nurse respond?
A) "Rehabilitation will reverse any physical deficits caused by the stroke."
B) "Rehabilitation will help you function at the highest level possible."
C) "If you do not have rehabilitation, you may never walk again."
D) "Your doctor knows best and has ordered this treatment for you." Answer: B
The goal of rehabilitation is to maximize the client's abilities in all aspects of life. The
other responses do not answer the client's question appropriately.
▶ The nurse is monitoring a client with hypoglycemia. Glucagon provides which
function?
A) It enhances the activity of insulin, restoring blood glucose levels to normal more
quickly after a high-calorie meal.
B) It prevents hypoglycemia by promoting release of glucose from liver storage sites.
C) It is a storage form of glucose and can be broken down for energy when blood
glucose levels are low.
D) It converts excess glucose into glycogen, lowering blood glucose levels in times of
excess. Answer: B
Glycogen is a counterregulatory hormone secreted by the alpha cells of the pancreas
when blood glucose levels are low. The actions of glycogen that raise blood glucose
levels include stimulating the liver to break down glycogen (glycogenolysis) and forming
new glucose from protein breakdown (gluconeogenesis). The other statements are not
accurate descriptions of the actions of glucagon.
▶ A client has a deep wound covered with a wet-to-damp dressing. Which intervention
does the nurse include on this client's care plan?
A) Apply a new dressing when the seal breaks and the dressing leaks.
B) Change the dressing when the current dressing is saturated.
C) Leave the dressing intact until next week.
D) Change the dressing every 6 hours around the clock. Answer: D
Wet-to-damp dressings are changed every 4 to 6 hours to provide maximum
débridement. Synthetic dressings can be left in place for extended periods of time but
, need to be changed if the seal breaks and the exudate is leaking. Dry gauze dressings
should be changed when the outer layer becomes saturated.
▶ A client is hospitalized with a urinary tract infection (UTI). Which clinical manifestation
alerts the nurse to the possibility of a complication from the UTI?
A) Hematuria
B) Fever and chills
C) Cloudy, dark urine
D) Burning on urination Answer: B
Lower urinary tract infections are rarely associated with systemic symptoms of fever and
chills. A client with a UTI who develops fever and chills should be assessed for the
development of pyelonephritis. The other options can be seen with UTI.
▶ The nurse observes a small opening that is draining purulent material on the skin
over the trochanter area of a bedridden client. Which is the nurse's next best action?
A) Probe for a larger pocket of necrotic tissue.
B) Apply alginate dressing daily.
C) Apply a transparent film dressing.
D) Measure the reddened area on the skin surface. Answer: A
This "hidden" wound may first be observed as a small opening in the skin through which
purulent drainage exudes. Applying a transparent film dressing would not help this type
of wound to heal. Measuring the reddened area would not assist in determining the
actual size of the wound, because internal damage has occurred. Alginate dressings
could not be applied if the area were not opened.
▶ When reviewing an older client's medical record, which findings lead the nurse to
perform a nutrition assessment? (Select all that apply.)
A) Widow/widower status
B) Chronic constipation
C) Cholecystectomy 4 years ago
D) Random blood sugar level of 198 mg/dL
E) History of depression
F) Inability to afford a new pair of glasses Answer: A,B,E,F
Many factors contribute to malnutrition in older clients. Depression and loneliness from
the loss of a spouse; constipation; poor eyesight; chronic medical problems, including
depression; and taking prescription and/or over-the-counter medications can contribute
to malnutrition. Blood glucose levels and a previous cholecystectomy would not
necessarily contribute.
SCRIPT 2026 FULL QUESTIONS AND CORRECT
ANSWERS AUTHENTIC FILE
▶ A client presents with a pressure ulcer on the ankle. Which is the first intervention
that the nurse implements?
A) Place the client in bed and instruct him or her to elevate the foot.
B) Prepare for and assist with obtaining a wound culture.
C) Assess the affected leg for pulses, skin color, and temperature.
D) Draw blood for albumin, prealbumin, and total protein. Answer: C
A client with an ulcer on the foot should be assessed for interruption in arterial flow to
the area. This begins with assessment of pulses and color and temperature of the skin.
The nurse can also assess for pulses noninvasively with a Doppler if unable to palpate
with his or her fingers. Elevation of the foot would impair the ability of arterial blood to
flow to the area. Wound cultures are done after it has been determined drainage, odor,
and other risks for infection are present. Tests to determine nutritional status and risk
assessment would be completed after the initial assessment is done.
▶ During assessment of a client with a 15-year history of diabetes, the nurse notes that
the client has decreased tactile sensation in both feet. Which action does the nurse take
first?
A) Notify the health care provider.
B) Document the finding in the client's chart.
C) Examine the client's feet for signs of injury.
D) Test sensory perception in the client's hands. Answer: C
Diabetic neuropathy is common when the disease is of long duration. The client is at
great risk for injury in any area with decreased sensation because he or she is less able
to feel injurious events. Feet are common locations for neuropathy and injury, so the
nurse should inspect them for any signs of injury. After assessing, the nurse should
document findings in the client's chart. Testing sensory perception in the hands may or
may not be needed. The health care provider can be notified after assessment and
documentation have been completed.
▶ Which nursing intervention best assists a bedridden client to keep skin intact?
A) Use a lift sheet to move the client in bed.
B) Turn the client every 2 to 4 hours.
C) Use a foam mattress pad.
D) Apply talcum powder to the perineal area. Answer: A
,Friction forces are generated when the client is dragged or pulled across bed linen; this
often leads to altered skin integrity. Using a lift sheet will prevent friction. Keeping the
skin clean and dry is an important intervention, but powders should not be used in the
perineal area. To minimize vasoconstriction and possible pressure ulcer development
from dependency, the client should be turned at a minimum of every 2 hours. A foam
mattress will not significantly decrease pressure to an area.
▶ A client presents with an acute exacerbation of multiple sclerosis. Which prescribed
medication does the nurse prepare to administer?
A) Interferon beta-1b (Betaseron)
B) Baclofen (Lioresal)
C) Methylprednisolone (Medrol)
D) Dantrolene sodium (Dantrium) Answer: C
Methylprednisolone is the drug of choice for acute exacerbations of the disease. The
other medications are not appropriate.
▶ The nurse is assessing a client's understanding of his hypertension therapy. What
client statement indicates a need for further teaching?
A) "When my blood pressure is normal, I will no longer need to take medication."
B) "If my blood pressure stays under control, I will reduce my risk for a heart attack."
C) "If I lose weight, I might be able to reduce my blood pressure medication."
D) "When getting out of bed in the morning, I will sit for a few moments then stand."
Answer: A
Compliance with antihypertensive therapy is difficult for two reasons. First, often clients
have no distressing symptoms associated with hypertension and may not believe that
they have a problem. Second, many clients believe that once blood pressure is brought
back into the normal range, they are "cured" and no longer need to take medication.
Losing weight might allow the client to reduce medications. Lowering blood pressure
does lower risk for heart attack. Because blood pressure medications often lead to
orthostatic hypotension, clients should be taught to change position slowly, sitting first
before standing after lying flat.
▶ Which of the following would be included in the assessment of a patient with diabetes
mellitus who is experiencing a hypoglycemic reaction? (Select all that apply.)
A) Constricted pupils
B) Flushed skin
C) Tremors
D) Nervousness
E) Extreme thirst
F) Profuse perspiration Answer: C,D,F
,When hypoglycemia occurs, blood glucose levels fall, resulting in sympathetic nervous
system responses such as tremors, nervousness, and profuse perspiration. Dilated
pupils would also occur, not constricted pupils. Extreme thirst, flushed skin, and
constricted pupils are consistent with hyperglycemia.
▶ A client who has had a stroke with left-sided hemiparesis has been referred to a
rehabilitation center. The client asks, "Why do I need rehabilitation?" How does the
nurse respond?
A) "Rehabilitation will reverse any physical deficits caused by the stroke."
B) "Rehabilitation will help you function at the highest level possible."
C) "If you do not have rehabilitation, you may never walk again."
D) "Your doctor knows best and has ordered this treatment for you." Answer: B
The goal of rehabilitation is to maximize the client's abilities in all aspects of life. The
other responses do not answer the client's question appropriately.
▶ The nurse is monitoring a client with hypoglycemia. Glucagon provides which
function?
A) It enhances the activity of insulin, restoring blood glucose levels to normal more
quickly after a high-calorie meal.
B) It prevents hypoglycemia by promoting release of glucose from liver storage sites.
C) It is a storage form of glucose and can be broken down for energy when blood
glucose levels are low.
D) It converts excess glucose into glycogen, lowering blood glucose levels in times of
excess. Answer: B
Glycogen is a counterregulatory hormone secreted by the alpha cells of the pancreas
when blood glucose levels are low. The actions of glycogen that raise blood glucose
levels include stimulating the liver to break down glycogen (glycogenolysis) and forming
new glucose from protein breakdown (gluconeogenesis). The other statements are not
accurate descriptions of the actions of glucagon.
▶ A client has a deep wound covered with a wet-to-damp dressing. Which intervention
does the nurse include on this client's care plan?
A) Apply a new dressing when the seal breaks and the dressing leaks.
B) Change the dressing when the current dressing is saturated.
C) Leave the dressing intact until next week.
D) Change the dressing every 6 hours around the clock. Answer: D
Wet-to-damp dressings are changed every 4 to 6 hours to provide maximum
débridement. Synthetic dressings can be left in place for extended periods of time but
, need to be changed if the seal breaks and the exudate is leaking. Dry gauze dressings
should be changed when the outer layer becomes saturated.
▶ A client is hospitalized with a urinary tract infection (UTI). Which clinical manifestation
alerts the nurse to the possibility of a complication from the UTI?
A) Hematuria
B) Fever and chills
C) Cloudy, dark urine
D) Burning on urination Answer: B
Lower urinary tract infections are rarely associated with systemic symptoms of fever and
chills. A client with a UTI who develops fever and chills should be assessed for the
development of pyelonephritis. The other options can be seen with UTI.
▶ The nurse observes a small opening that is draining purulent material on the skin
over the trochanter area of a bedridden client. Which is the nurse's next best action?
A) Probe for a larger pocket of necrotic tissue.
B) Apply alginate dressing daily.
C) Apply a transparent film dressing.
D) Measure the reddened area on the skin surface. Answer: A
This "hidden" wound may first be observed as a small opening in the skin through which
purulent drainage exudes. Applying a transparent film dressing would not help this type
of wound to heal. Measuring the reddened area would not assist in determining the
actual size of the wound, because internal damage has occurred. Alginate dressings
could not be applied if the area were not opened.
▶ When reviewing an older client's medical record, which findings lead the nurse to
perform a nutrition assessment? (Select all that apply.)
A) Widow/widower status
B) Chronic constipation
C) Cholecystectomy 4 years ago
D) Random blood sugar level of 198 mg/dL
E) History of depression
F) Inability to afford a new pair of glasses Answer: A,B,E,F
Many factors contribute to malnutrition in older clients. Depression and loneliness from
the loss of a spouse; constipation; poor eyesight; chronic medical problems, including
depression; and taking prescription and/or over-the-counter medications can contribute
to malnutrition. Blood glucose levels and a previous cholecystectomy would not
necessarily contribute.
