Nursing 1600 Quiz 6 ATI Practice Questions with Rationales
1. A nurse is caring for an infant who is dehydrated and requires therapy. The nurse should monitor the infant's
response to therapy by
a. weighing the infant at the same time every day.
R Weight is the most sensitive indicator of hydration status for clients of all ages. Weight
is the only measurement that reflects both measurable fluid balance changes and
incidental fluid loss.
b. taking the infant's vital signs every 2 hr.
R Vital signs are not a reliable indicator of hydration status.
c. measuring the infant's head circumference twice a day.
R Measuring head circumference gives no useful information regarding the hydration
status of the infant.
d. counting the number of wet diapers every shift.
R Counting wet diapers is inadequate to accurately determine the hydration status of the
infant.
2. A nurse is caring for a toddler whose parent states while bathing the child she noticed a mass in his
abdominal area and his urine is a pink color. Which of the following is the priority action the nurse
should take?
a. Schedule the child for an abdominal ultrasound.
R While it is important to schedule the child for an ultrasound, this is not the nurse‘s priority
action.
b. Instruct the parent to avoid pressing on the abdominal area.
R The priority action by the nurse is to instruct the parent to avoid pressing on the child‘s
abdominal. These symptoms are associated with Wilm‘s tumor, and trauma to the mass
should be avoided to prevent entry of cancer cells into other sites.
c. Determine if the child is having pain.
R While it is important to determine if the child is having pain, this is not the nurse‘s priority
action.
d. Obtain a urine specimen for a urinalysis.
R While it is important to obtain a urine specimen for a urinalysis, this is not the nurse‘
s priority action.
3. A nurse is assisting with the discharge of a child with sickle cell anemia after an acute crisis episode.
Which of the following should the nurse reinforce with the child‘s parents?
a. Monitor the child‘s temperature daily.
R The parents only need to check the child‘s temperature when they suspect fever, and
when they do, they should report it to the provider immediately. Fever is a
manifestation of acute chest syndrome, a complication of sickle cell anemia.
b. Restrict outdoor play activity to 1 hr per
day. R The child may play as
usual.
c. Encourage the child to drink lots of fluids.
R Preventing dehydration is an important step in preventing a sickle cell crisis. The nurse
should give the parents a specific amount of fluid to make should the child drinks each
day.
d. Have the child eat a high-protein diet.
R The child should eat a well-balanced diet, not unusually high in protein.
4. A nurse is collecting data regarding the pain level of a 4-year-old client on the second postoperative day.
Which of the following actions should the nurse take?
a. Ask the client what number the pain is on a scale from 1 to 10.
R An ordinal scale is not appropriate to use with a 4-year-old client.
b. Tell the client to point to a face on a FACES Pain Rating Scale.
R The FACES Pain Rating Scale is an age appropriate pain assessment tool for a 4- year-old
client.
c. Have the parent report the pain level for the client.
R The nurse should use an age appropriate pain rating scale for a 4-year-old client. The
parent may not be able to accurately report the client's pain level.
d. Request an assistive personnel to evaluate the client's pain level.
R Determining a 4-year-old client's pain level is not within the scope of practice of an
assistive personnel.
,Nursing 1600 Quiz 6 ATI Practice Questions with Rationales
5. A nurse is caring for a child who has idiopathic thrombocytopenic purpura and is experiencing a nose
bleed. Which of the following is an appropriate action by the nurse?
a. Apply ice to the back of the neck.
R The nurse should apply ice, or a cold cloth, to the bridge of the nose instead of the
back of the neck.
b. Position the child supine.
, Nursing 1600 Quiz 6 ATI Practice Questions with Rationales
R To prevent aspiration, the nurse should position the child sitting up and leaning
forward, not supine.
c. Insert cotton into each nostril.
R The nurse should insert cotton into each nostril to assist with controlling the bleeding.
d. Tilt the child‘s head back.
R The nurse should tilt the child‘s head forward, not back.
6. A nurse is caring for an adolescent who is admitted with sickle cell crisis. Which of the following nursing
actions should be performed?
a. Withhold narcotics to avoid dependence.
R This is not an appropriate nursing action. Narcotics should not be withheld from a client
in sickle cell crisis.
b. Place client on a 2 L/day fluid restriction.
R This is not an appropriate nursing action. Increasing fluid intake helps prevent
dehydration vaso- occlusion.
c. Encourage exercise.
R This is not an appropriate nursing action. During a sickle cell crisis, activity should be
minimized.
Clients are usually placed on bed rest to decrease the need for oxygen by the cells.
d. Administer oxygen via nasal cannula.
R This is an appropriate nursing action. Hemoglobin S forms a sickled shape in the
presence of low oxygen tension, and oxygen is administered to prevent the condition of
low oxygen tension.
7. A nurse is caring for a 4-year-old client following abdominal surgery. Which of the following statements is
appropriate for the nurse to use to encourage the child to take deep breaths?
a. "You can't go to the playroom until you finish doing your deep breathing."
R This is a punitive remark that the child could perceive as a threat or a challenge.
b. "Let's play a game of blowing cotton balls across your table."
R By engaging the child in a form of play, the nurse may distract him from the
discomfort of deep breathing.
c. "I'll leave your blow bottle here on your table, so you can use it yourself like a big kid."
R Since deep breathing will be uncomfortable, it is unlikely that the child will perform
it without coaching.
d. "I will give you a sticker each time you take a deep breath."
R This action is going to be painful, and the child may not respond to positive
reinforcement after the pain.
8. A nurse is providing teaching for a client who has anemia and a new prescription for ferrous sulfate
liquid. Which of the following instructions should the nurse provide?
a. Take the medication on an empty stomach to decrease gastrointestinal irritation.
R Taking iron on an empty stomach may increase gastrointestinal side effects.
b. Take the medication with orange juice to enhance absorption.
R Ascorbic acid (vitamin C), which is found in orange juice, will enhance the absorption
of iron and increase its bioavailability. This will also help to decrease the
gastrointestinal side effects of iron.
c. Take the medication with milk.
R Iron should not be taken with milk or antacids, because it decreases the absorption.
d. Rinse the mouth before taking the iron.
R The client should rinse the mouth after taking the ferrous sulfate liquid to prevent the
medication from staining the teeth.
9. A nurse is providing teaching to a client who has neutropenia. Which of the following information
should the nurse include in the teaching?
a. Eat plenty of fresh fruits and vegetables.
R The nurse should inform a client who is neutropenic to avoid fresh fruits and vegetables
due to the bacteria they can carry.
b. Avoid crowds.
R The nurse should inform the client to avoid crowds due to his suppressed immune system.
c. Perform mild exercise, such as gardening.
R The nurse should instruct the client to avoid gardening due bacteria contained in the soil.
d. Take temperature weekly.
R A client who is neutropenic can experience a 1° increase from his baseline
temperature, even in the presence of infection. Therefore, the nurse should recommend
the client take his temperature at least once daily
1. A nurse is caring for an infant who is dehydrated and requires therapy. The nurse should monitor the infant's
response to therapy by
a. weighing the infant at the same time every day.
R Weight is the most sensitive indicator of hydration status for clients of all ages. Weight
is the only measurement that reflects both measurable fluid balance changes and
incidental fluid loss.
b. taking the infant's vital signs every 2 hr.
R Vital signs are not a reliable indicator of hydration status.
c. measuring the infant's head circumference twice a day.
R Measuring head circumference gives no useful information regarding the hydration
status of the infant.
d. counting the number of wet diapers every shift.
R Counting wet diapers is inadequate to accurately determine the hydration status of the
infant.
2. A nurse is caring for a toddler whose parent states while bathing the child she noticed a mass in his
abdominal area and his urine is a pink color. Which of the following is the priority action the nurse
should take?
a. Schedule the child for an abdominal ultrasound.
R While it is important to schedule the child for an ultrasound, this is not the nurse‘s priority
action.
b. Instruct the parent to avoid pressing on the abdominal area.
R The priority action by the nurse is to instruct the parent to avoid pressing on the child‘s
abdominal. These symptoms are associated with Wilm‘s tumor, and trauma to the mass
should be avoided to prevent entry of cancer cells into other sites.
c. Determine if the child is having pain.
R While it is important to determine if the child is having pain, this is not the nurse‘s priority
action.
d. Obtain a urine specimen for a urinalysis.
R While it is important to obtain a urine specimen for a urinalysis, this is not the nurse‘
s priority action.
3. A nurse is assisting with the discharge of a child with sickle cell anemia after an acute crisis episode.
Which of the following should the nurse reinforce with the child‘s parents?
a. Monitor the child‘s temperature daily.
R The parents only need to check the child‘s temperature when they suspect fever, and
when they do, they should report it to the provider immediately. Fever is a
manifestation of acute chest syndrome, a complication of sickle cell anemia.
b. Restrict outdoor play activity to 1 hr per
day. R The child may play as
usual.
c. Encourage the child to drink lots of fluids.
R Preventing dehydration is an important step in preventing a sickle cell crisis. The nurse
should give the parents a specific amount of fluid to make should the child drinks each
day.
d. Have the child eat a high-protein diet.
R The child should eat a well-balanced diet, not unusually high in protein.
4. A nurse is collecting data regarding the pain level of a 4-year-old client on the second postoperative day.
Which of the following actions should the nurse take?
a. Ask the client what number the pain is on a scale from 1 to 10.
R An ordinal scale is not appropriate to use with a 4-year-old client.
b. Tell the client to point to a face on a FACES Pain Rating Scale.
R The FACES Pain Rating Scale is an age appropriate pain assessment tool for a 4- year-old
client.
c. Have the parent report the pain level for the client.
R The nurse should use an age appropriate pain rating scale for a 4-year-old client. The
parent may not be able to accurately report the client's pain level.
d. Request an assistive personnel to evaluate the client's pain level.
R Determining a 4-year-old client's pain level is not within the scope of practice of an
assistive personnel.
,Nursing 1600 Quiz 6 ATI Practice Questions with Rationales
5. A nurse is caring for a child who has idiopathic thrombocytopenic purpura and is experiencing a nose
bleed. Which of the following is an appropriate action by the nurse?
a. Apply ice to the back of the neck.
R The nurse should apply ice, or a cold cloth, to the bridge of the nose instead of the
back of the neck.
b. Position the child supine.
, Nursing 1600 Quiz 6 ATI Practice Questions with Rationales
R To prevent aspiration, the nurse should position the child sitting up and leaning
forward, not supine.
c. Insert cotton into each nostril.
R The nurse should insert cotton into each nostril to assist with controlling the bleeding.
d. Tilt the child‘s head back.
R The nurse should tilt the child‘s head forward, not back.
6. A nurse is caring for an adolescent who is admitted with sickle cell crisis. Which of the following nursing
actions should be performed?
a. Withhold narcotics to avoid dependence.
R This is not an appropriate nursing action. Narcotics should not be withheld from a client
in sickle cell crisis.
b. Place client on a 2 L/day fluid restriction.
R This is not an appropriate nursing action. Increasing fluid intake helps prevent
dehydration vaso- occlusion.
c. Encourage exercise.
R This is not an appropriate nursing action. During a sickle cell crisis, activity should be
minimized.
Clients are usually placed on bed rest to decrease the need for oxygen by the cells.
d. Administer oxygen via nasal cannula.
R This is an appropriate nursing action. Hemoglobin S forms a sickled shape in the
presence of low oxygen tension, and oxygen is administered to prevent the condition of
low oxygen tension.
7. A nurse is caring for a 4-year-old client following abdominal surgery. Which of the following statements is
appropriate for the nurse to use to encourage the child to take deep breaths?
a. "You can't go to the playroom until you finish doing your deep breathing."
R This is a punitive remark that the child could perceive as a threat or a challenge.
b. "Let's play a game of blowing cotton balls across your table."
R By engaging the child in a form of play, the nurse may distract him from the
discomfort of deep breathing.
c. "I'll leave your blow bottle here on your table, so you can use it yourself like a big kid."
R Since deep breathing will be uncomfortable, it is unlikely that the child will perform
it without coaching.
d. "I will give you a sticker each time you take a deep breath."
R This action is going to be painful, and the child may not respond to positive
reinforcement after the pain.
8. A nurse is providing teaching for a client who has anemia and a new prescription for ferrous sulfate
liquid. Which of the following instructions should the nurse provide?
a. Take the medication on an empty stomach to decrease gastrointestinal irritation.
R Taking iron on an empty stomach may increase gastrointestinal side effects.
b. Take the medication with orange juice to enhance absorption.
R Ascorbic acid (vitamin C), which is found in orange juice, will enhance the absorption
of iron and increase its bioavailability. This will also help to decrease the
gastrointestinal side effects of iron.
c. Take the medication with milk.
R Iron should not be taken with milk or antacids, because it decreases the absorption.
d. Rinse the mouth before taking the iron.
R The client should rinse the mouth after taking the ferrous sulfate liquid to prevent the
medication from staining the teeth.
9. A nurse is providing teaching to a client who has neutropenia. Which of the following information
should the nurse include in the teaching?
a. Eat plenty of fresh fruits and vegetables.
R The nurse should inform a client who is neutropenic to avoid fresh fruits and vegetables
due to the bacteria they can carry.
b. Avoid crowds.
R The nurse should inform the client to avoid crowds due to his suppressed immune system.
c. Perform mild exercise, such as gardening.
R The nurse should instruct the client to avoid gardening due bacteria contained in the soil.
d. Take temperature weekly.
R A client who is neutropenic can experience a 1° increase from his baseline
temperature, even in the presence of infection. Therefore, the nurse should recommend
the client take his temperature at least once daily
