Peds ATI 2019 A
1. A nurse is caring for a school-age child who is receiving cefazolin via intermittent IV bolus. The child
suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication
infusion, which of the following medications should the nurse administer first?: epinephrine
2. A nurse is teaching the parent of an infant about ways to prevent sudden infant death syndrome
(SIDS). Which of the following instructions should the nurse include?: give the infant a pacifier
3. A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the following
findings should the nurse expect? (Select all that apply.): -Ankle clonus-Exaggerated stretch reflexes-
Contractures
4. The nurse is providing discharge teaching to the parent of a child who is 1 week postoperative
following a cleft palate repair. For which of the following members of the inter professional team
should the nurse initiate a referral?: speech therapist
5. 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.
Therefore, the nurse should implement seizure precautions for the child.
6. A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should the
nurse take?: apply a topical analgesic cream to the site 1 hr prior to procedure
7. A nurse is providing teaching to the 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.
8. A nurse in an emergency department is performing an admission 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
, 9. A nurse is receiving change-of-shift report on four children. Which of the following children should
the nurse see first?: A school-age child who has sickle cell anemia and reports decreased vision in the left
eye.When using the urgent vs. nonurgent approach to client care, the nurse should determine the priority
finding is a report of decreased vision in the left eye. This finding indicates that the child is experiencing a
vaso-occlusive crisis and should be reported to the provider immediately. Therefore, the nurse should see
this child first.
10. A nurse is assessing a school-age child who has meningitis. Which of the following findings is the
priority for the nurse to report to the provider?: Petechiae on the lower extremitiesThe presence of a
petechial or purpuric rash on a child who is ill can indicate the presence of meningococcemia. This type of
rash indicates the greatest risk of serious rapid complications from sepsis and should be reported
immediately to the provider.
11. A nurse is assessing a 3-year-old toddler at a well-child visit. Which of the following manifestations
should the nurse report to the provider?: Respiratory rate 45/minThe nurse should identify that a
respiratory rate of 45/min is above the expected reference range of 20 to 25/min for a 3-year-old toddler and
can indicate respiratory dysfunction and acute respiratory distress. Therefore, the nurse should report this
finding to the provider.
12. A nurse is reviewing the laboratory 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. The child can exhibit fatigue, lightheadedness, tachycardia, dyspnea, and pallor due to the
decreased oxygen-carrying capacity.
13. A nurse is planning care for a school-age child who is in the oliguric phase of acute kidney injury
(AKI) and has a sodium level of 129 mEq/L. Which of the following interventions should the nurse
include in the plan?: Initiate seizure precautions for the child.A sodium level of 129 mEq/L indicates
hyponatremia and places the child at increased risk for neurological deficits and seizure activity. The nurse
should complete a neurologic assessment and implement seizure precautions to maintain the child's safety.
14. A nurse is assessing the vital signs of a 10-year-old child following a burn injury. The nurse should
identify that which of the following findings in an indication of early septic shock?: Temperature 39.1°
C (102.4° F)The nurse should identify that a temperature of 39.1° C (102.4° F) is above the expected
reference range of 37° to 37.5° C (98.6° to 99.5° F) for a 10-year-old child. The nurse should expect a child
who has early septic shock to have a fever and chills.
1. A nurse is caring for a school-age child who is receiving cefazolin via intermittent IV bolus. The child
suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication
infusion, which of the following medications should the nurse administer first?: epinephrine
2. A nurse is teaching the parent of an infant about ways to prevent sudden infant death syndrome
(SIDS). Which of the following instructions should the nurse include?: give the infant a pacifier
3. A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the following
findings should the nurse expect? (Select all that apply.): -Ankle clonus-Exaggerated stretch reflexes-
Contractures
4. The nurse is providing discharge teaching to the parent of a child who is 1 week postoperative
following a cleft palate repair. For which of the following members of the inter professional team
should the nurse initiate a referral?: speech therapist
5. 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.
Therefore, the nurse should implement seizure precautions for the child.
6. A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should the
nurse take?: apply a topical analgesic cream to the site 1 hr prior to procedure
7. A nurse is providing teaching to the 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.
8. A nurse in an emergency department is performing an admission 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
, 9. A nurse is receiving change-of-shift report on four children. Which of the following children should
the nurse see first?: A school-age child who has sickle cell anemia and reports decreased vision in the left
eye.When using the urgent vs. nonurgent approach to client care, the nurse should determine the priority
finding is a report of decreased vision in the left eye. This finding indicates that the child is experiencing a
vaso-occlusive crisis and should be reported to the provider immediately. Therefore, the nurse should see
this child first.
10. A nurse is assessing a school-age child who has meningitis. Which of the following findings is the
priority for the nurse to report to the provider?: Petechiae on the lower extremitiesThe presence of a
petechial or purpuric rash on a child who is ill can indicate the presence of meningococcemia. This type of
rash indicates the greatest risk of serious rapid complications from sepsis and should be reported
immediately to the provider.
11. A nurse is assessing a 3-year-old toddler at a well-child visit. Which of the following manifestations
should the nurse report to the provider?: Respiratory rate 45/minThe nurse should identify that a
respiratory rate of 45/min is above the expected reference range of 20 to 25/min for a 3-year-old toddler and
can indicate respiratory dysfunction and acute respiratory distress. Therefore, the nurse should report this
finding to the provider.
12. A nurse is reviewing the laboratory 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. The child can exhibit fatigue, lightheadedness, tachycardia, dyspnea, and pallor due to the
decreased oxygen-carrying capacity.
13. A nurse is planning care for a school-age child who is in the oliguric phase of acute kidney injury
(AKI) and has a sodium level of 129 mEq/L. Which of the following interventions should the nurse
include in the plan?: Initiate seizure precautions for the child.A sodium level of 129 mEq/L indicates
hyponatremia and places the child at increased risk for neurological deficits and seizure activity. The nurse
should complete a neurologic assessment and implement seizure precautions to maintain the child's safety.
14. A nurse is assessing the vital signs of a 10-year-old child following a burn injury. The nurse should
identify that which of the following findings in an indication of early septic shock?: Temperature 39.1°
C (102.4° F)The nurse should identify that a temperature of 39.1° C (102.4° F) is above the expected
reference range of 37° to 37.5° C (98.6° to 99.5° F) for a 10-year-old child. The nurse should expect a child
who has early septic shock to have a fever and chills.
