ATI PED A
A nurse in a providers office is preparing to administer immunizations to a toddler during
a well child visit. Which of the following actions should the nurse plan to take?
Provider Prescriptions:
Tuberculin skin test (TST)Measles, mumps, and rubella (MMR) vaccineInactivated
influenza vaccineDiphtheria, tetanus, and pertussis (DTaP) vaccine
Graphic Record:
Respiratory rate 24/minHeart rate 115/minTemperature 36.9° C (98.4° F)
History and Physical:
Age 15 months Height 71.1 cm (28 in) Allergies Neomycin (anaphylactic reaction)
Caregiver reports rhinitis with clear nasal drainage for 2 daysOccasional nonproductive
cough for 2 days History of asthma
Withhold the MMR Vaccine.
The nurse should recognize that an allergy to neomycin with an anaphylactic reaction is
a contraindication for receiving the MMR Vaccine. Clients who have severe allergy to
eggs or gelatin should not receive this vaccine.
A nurse is providing teaching to a parent of a school age child who has a new
prescription for oral nystatin for the treatment of oral candidiasis. Which of the following
instructions should the nurse include?
"Shake the medication prior to administration"
The nurse should instruct the parent to shake the medication prior to administration to
disperse the medication evenly within the suspension.
A nurse is reviewing the lumbar puncture results of a school age child who is suspected
of having bacterial meningitis. Which of the following findings should the nurse identify
as an indication of bacterial meningitis?
Increased protein concentration.
The nurse should identify that an increased protein concentration in the spinal fluid is a
finding that can indicate bacterial meningitis.
A nurse is caring for a preschooler whose father is going home for a few hours while
another relative stays with the child. Which of the following statements should the nurse
make to explain to the child when their father will return?
"Your daddy will be back after you eat"
Preschoolers make sense of time best when they can associate it with an expected
daily routine, such as meals and bedtime.
A nurse is reviewing the lab report of a school age child who is experiencing fatigue.
Which of the following findings should the nurse recognize as an indication of anemia?
Hematocrit 28%
,The nurse should recognize that this hematocrit level is below the expected reference
range of 32% to 44% for a school age child. Child can exhibit fatigue, lightheadedness,
tachycardia, dyspnea, & pallor due to decreased oxygen carrying capacity
A nurse is reviewing the laboratory report of an infant who is receiving the treatment for
severe dehydration. The nurse should identify that which of the following laboratory
values indicates effectiveness of the current treatment?
sodium 140 mEq/L
The nurse should identify that a sodium level of 140 is within the expected reference
range of 134 to 150 and indicates the current treatment for dehydration is effective.
A nurse is reviewing the lab report of a 7year old who is reviving chemo. Which of ht e
following lab values should the nurse report to the provider?
HgB 8.5 g/dL
A child receiving chemo is at risk for anemia due to the chemo effects on the blood
forming cells of the bone marrow. The development of anemia is diagnosed through lab
testing of hemoglobin and hematocrit levels. Expected range is 10-15.5 g/dL for a 7year
old.
A nurse is teaching the parent of an infant about ways to prevent sudden infant
syndrome (SIDS). Which of the following instructions should the nurse include?
"Give the infant a pacifier at bedtime."
The nurse should inform the parent that protective factors against SIDS includes
breastfeeding and the use of a pacifier when the infant is sleeping.
A nurse is caring for a preschooler who has been receiving IV fluids via a peripheral IV
catheter. When preparing to discontinue the IV fluids and catheter, which of the
following actions should the nurse plan to take?
Place the steps incorrect order.
1. Turn off IV Pump
2. Occlude the IV tubing.
3. Remove the tape securing the catheter.
4. Apply pressure over the catheter insertion site.
A school nurse is assessing an adolescent who has multiple burns in various stages of
healing. Which of the following behaviors should the nurse identify as a possible
indication of physical abuse?
Denies discomfort during assessment of injuries.
The nurse should suspect child maltreatment in the form of physical abuse if the
adolescent has a blunted response to painful stimuli or injury.
,A nurse is teaching a parent of an infant who has a pavlik harness for the treatment of
development dysplasia of the hip. The nurse should identify that which of the following
statements by the parent indicates an understanding of the teaching?
"I will place my infants diapers under the harness straps"
To prevent soiling of the harness, the parent should apply the infants diaper under the
straps.
A nurse is assessing a school age child who has peritonitis. Which of the following
findings should the nurse expect?
Abdominal Distention
The nurse should identify that abdominal distention is an expected finding of peritonitis.
Peritonitis is an inflammation of the lining of the abdominal wall. This inflammation in the
abdomen, along with the ileus that develops, causes abdominal distention. Other
manifestations include chills, irritability, & restlessness.
A school nurse is assessing an adolescent who has scoliosis. Which of the following
findings should the nurse expect?
A unilateral rib hump.
When assessing an adolescent for scoliosis, the school nurse should expect to see a
unilateral rib hump with hip flexion. This results from a lateral S or C shaped curvature
to the thoracic spine resulting in asymmetry of the ribs, shoulders, hips, or pelvis.
A nurse is assessing a school age child immediately following a perforated appendix
repair. Which of the following findings should the nurse expect?
Absence of peristalsis.
The nurse should expect absence of peristalsis immediately following a perforated
appendix repair, until the bowl resumes functioning.
A nurse is providing discharge teaching to the parent of child who is 1 week
postoperative following a cleft palate repair. For which of the following members of the
interprofessional team should the nurse initiate a referral?
Speech Therapist
A child who has a cleft palate will require speech therapy immediately following the
repair to support speech development & future articulation.
A hospice nurse is caring for a preschooler who has a terminal illness. One of the
preschoolers parents tells the nurse that they cannot cope anymore and are thinking
about moving out of the house. Which of the following statements should the nurse
make?
"Lets talk about some of the ways you have handled previous stressors in your life."
, This statement offers a general lead to allow the parent to express their feelings and
previous actions when faced with stressful situations. It also helps the parent to focus
on ways that they can cope with the current situation.
A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions
should the nurse take?
Apply topical analgesic cream to the site 1 hr prior to the procedure.
This decreases the adolescents pain while the lumbar needle is inserted.
A nurse in an emergency department is performing a physical assessment on a 2 week
old male newborn. Which of the following findings is the priority for the nurse to report to
the provider?
Substernal retractions.
When using the airway, breathing and circulation approach to client care, the nurse
should determine priority finding to report to the provider is substernal retractions. The
finding indicates the newborn is experiencing increased respiratory effort, wi=which
could quickly progress to respiratory failure.
A nurse is providing teaching about play activities for social development to the parents
of a preschooler. Which of the following play activities should the nurse recommend for
the child?
Playing dress-up
At preschool age, play should focus on social, mental and physical development.
Therefore, playing dress-up is a recommended play activity for this child.
A nurse is creating a plan of care for an infant who has an epidural hematoma from a
head injury. Which of the following interventions should the nurse include in the plan?
Implement seizure precautions for the infant.
An infant who has an epidural hematoma is at great risk for seizure activity.
A nurse is admitting a school age child who has pertussis. Which of the following
actions should the nurse take?
Initiate droplet precautions for the child.
Also known as whopping cough, it is transmitted through contact with infected large
droplet nuclei that are suspended in the air when the child cough, sneezes or talks.
A nurse is caring for a preschooler who is scheduled for hydrotherapy treatment for a
wound debridement following a burn. Which of the following actions should the nurse
tae prior to the procedure?
Administer an analgesic to the child.
A nurse in a providers office is preparing to administer immunizations to a toddler during
a well child visit. Which of the following actions should the nurse plan to take?
Provider Prescriptions:
Tuberculin skin test (TST)Measles, mumps, and rubella (MMR) vaccineInactivated
influenza vaccineDiphtheria, tetanus, and pertussis (DTaP) vaccine
Graphic Record:
Respiratory rate 24/minHeart rate 115/minTemperature 36.9° C (98.4° F)
History and Physical:
Age 15 months Height 71.1 cm (28 in) Allergies Neomycin (anaphylactic reaction)
Caregiver reports rhinitis with clear nasal drainage for 2 daysOccasional nonproductive
cough for 2 days History of asthma
Withhold the MMR Vaccine.
The nurse should recognize that an allergy to neomycin with an anaphylactic reaction is
a contraindication for receiving the MMR Vaccine. Clients who have severe allergy to
eggs or gelatin should not receive this vaccine.
A nurse is providing teaching to a parent of a school age child who has a new
prescription for oral nystatin for the treatment of oral candidiasis. Which of the following
instructions should the nurse include?
"Shake the medication prior to administration"
The nurse should instruct the parent to shake the medication prior to administration to
disperse the medication evenly within the suspension.
A nurse is reviewing the lumbar puncture results of a school age child who is suspected
of having bacterial meningitis. Which of the following findings should the nurse identify
as an indication of bacterial meningitis?
Increased protein concentration.
The nurse should identify that an increased protein concentration in the spinal fluid is a
finding that can indicate bacterial meningitis.
A nurse is caring for a preschooler whose father is going home for a few hours while
another relative stays with the child. Which of the following statements should the nurse
make to explain to the child when their father will return?
"Your daddy will be back after you eat"
Preschoolers make sense of time best when they can associate it with an expected
daily routine, such as meals and bedtime.
A nurse is reviewing the lab report of a school age child who is experiencing fatigue.
Which of the following findings should the nurse recognize as an indication of anemia?
Hematocrit 28%
,The nurse should recognize that this hematocrit level is below the expected reference
range of 32% to 44% for a school age child. Child can exhibit fatigue, lightheadedness,
tachycardia, dyspnea, & pallor due to decreased oxygen carrying capacity
A nurse is reviewing the laboratory report of an infant who is receiving the treatment for
severe dehydration. The nurse should identify that which of the following laboratory
values indicates effectiveness of the current treatment?
sodium 140 mEq/L
The nurse should identify that a sodium level of 140 is within the expected reference
range of 134 to 150 and indicates the current treatment for dehydration is effective.
A nurse is reviewing the lab report of a 7year old who is reviving chemo. Which of ht e
following lab values should the nurse report to the provider?
HgB 8.5 g/dL
A child receiving chemo is at risk for anemia due to the chemo effects on the blood
forming cells of the bone marrow. The development of anemia is diagnosed through lab
testing of hemoglobin and hematocrit levels. Expected range is 10-15.5 g/dL for a 7year
old.
A nurse is teaching the parent of an infant about ways to prevent sudden infant
syndrome (SIDS). Which of the following instructions should the nurse include?
"Give the infant a pacifier at bedtime."
The nurse should inform the parent that protective factors against SIDS includes
breastfeeding and the use of a pacifier when the infant is sleeping.
A nurse is caring for a preschooler who has been receiving IV fluids via a peripheral IV
catheter. When preparing to discontinue the IV fluids and catheter, which of the
following actions should the nurse plan to take?
Place the steps incorrect order.
1. Turn off IV Pump
2. Occlude the IV tubing.
3. Remove the tape securing the catheter.
4. Apply pressure over the catheter insertion site.
A school nurse is assessing an adolescent who has multiple burns in various stages of
healing. Which of the following behaviors should the nurse identify as a possible
indication of physical abuse?
Denies discomfort during assessment of injuries.
The nurse should suspect child maltreatment in the form of physical abuse if the
adolescent has a blunted response to painful stimuli or injury.
,A nurse is teaching a parent of an infant who has a pavlik harness for the treatment of
development dysplasia of the hip. The nurse should identify that which of the following
statements by the parent indicates an understanding of the teaching?
"I will place my infants diapers under the harness straps"
To prevent soiling of the harness, the parent should apply the infants diaper under the
straps.
A nurse is assessing a school age child who has peritonitis. Which of the following
findings should the nurse expect?
Abdominal Distention
The nurse should identify that abdominal distention is an expected finding of peritonitis.
Peritonitis is an inflammation of the lining of the abdominal wall. This inflammation in the
abdomen, along with the ileus that develops, causes abdominal distention. Other
manifestations include chills, irritability, & restlessness.
A school nurse is assessing an adolescent who has scoliosis. Which of the following
findings should the nurse expect?
A unilateral rib hump.
When assessing an adolescent for scoliosis, the school nurse should expect to see a
unilateral rib hump with hip flexion. This results from a lateral S or C shaped curvature
to the thoracic spine resulting in asymmetry of the ribs, shoulders, hips, or pelvis.
A nurse is assessing a school age child immediately following a perforated appendix
repair. Which of the following findings should the nurse expect?
Absence of peristalsis.
The nurse should expect absence of peristalsis immediately following a perforated
appendix repair, until the bowl resumes functioning.
A nurse is providing discharge teaching to the parent of child who is 1 week
postoperative following a cleft palate repair. For which of the following members of the
interprofessional team should the nurse initiate a referral?
Speech Therapist
A child who has a cleft palate will require speech therapy immediately following the
repair to support speech development & future articulation.
A hospice nurse is caring for a preschooler who has a terminal illness. One of the
preschoolers parents tells the nurse that they cannot cope anymore and are thinking
about moving out of the house. Which of the following statements should the nurse
make?
"Lets talk about some of the ways you have handled previous stressors in your life."
, This statement offers a general lead to allow the parent to express their feelings and
previous actions when faced with stressful situations. It also helps the parent to focus
on ways that they can cope with the current situation.
A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions
should the nurse take?
Apply topical analgesic cream to the site 1 hr prior to the procedure.
This decreases the adolescents pain while the lumbar needle is inserted.
A nurse in an emergency department is performing a physical assessment on a 2 week
old male newborn. Which of the following findings is the priority for the nurse to report to
the provider?
Substernal retractions.
When using the airway, breathing and circulation approach to client care, the nurse
should determine priority finding to report to the provider is substernal retractions. The
finding indicates the newborn is experiencing increased respiratory effort, wi=which
could quickly progress to respiratory failure.
A nurse is providing teaching about play activities for social development to the parents
of a preschooler. Which of the following play activities should the nurse recommend for
the child?
Playing dress-up
At preschool age, play should focus on social, mental and physical development.
Therefore, playing dress-up is a recommended play activity for this child.
A nurse is creating a plan of care for an infant who has an epidural hematoma from a
head injury. Which of the following interventions should the nurse include in the plan?
Implement seizure precautions for the infant.
An infant who has an epidural hematoma is at great risk for seizure activity.
A nurse is admitting a school age child who has pertussis. Which of the following
actions should the nurse take?
Initiate droplet precautions for the child.
Also known as whopping cough, it is transmitted through contact with infected large
droplet nuclei that are suspended in the air when the child cough, sneezes or talks.
A nurse is caring for a preschooler who is scheduled for hydrotherapy treatment for a
wound debridement following a burn. Which of the following actions should the nurse
tae prior to the procedure?
Administer an analgesic to the child.
