NR328 Pediatric Nursing - ATI Learning System RN 3.0 Quiz - Answer KEY (Nursing Care of Children 1)

crying and holding a container of toilet bowl cleaner. The child's lips are edematous and inflamed, and he is drooling. Which of the following is the priority action by the nurse? a. Remove the child's contaminated clothing. b. Check the child's respiratory status. c. Administer an antidote to the child. d. Establish IV access for the child. Rationale: The nurse should apply the ABC priority-setting framework when answering this item. 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. 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. The nurse observes that the child’s lips are edematous and inflamed and that he is drooling. These findings indicate that the child might have swelling of the oral cavity and pharynx, which can result in a compromised airway. 2. A nurse is teaching a parent of a 12-month old child about development during the toddleryears. Which of the following statements should the nurse include? a. "Your child should be referring to himself using the appropriate pronoun by 18 months of age." b. "A toddler's interest in looking at pictures occurs at 20 months of age." c. "A toddler should have daytime control of his bowel and bladder by 24 months of age." d. "Your child should be able to scribble spontaneously using a crayon at the age of 15 months." Rationale: The nurse should teach the parent that at the age of 15 months, the toddler should be able to scribble spontaneously, and at the age of 18 months, the toddler should be able to make strokes imitatively. 3. A nurse is caring for a toddler and is preparing to administer 0.9% sodium chloride 100 mL IV to infuse over 4 hr. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) 25 gtt Rationale: 100ml/4 hr x 60gtt/1mlx 1 hr/60min= 6000/240= 25 gtt Ratio and Proportion STEP 1: What is the unit of measurement to calculate? gtt/min STEP 2: What is the volume needed? 100 mL STEP 3: What is the total infusion time? 4 hr STEP 4: Should the nurse convert the units of measurement? Yes (min does not equal hr) 1 hr/60 min = 4 hr/X min X = 240 min STEP 5: Set up an equation and solve for X. Volume (mL)/Time (min) = drop factor (gtt/mL) = X 100 mL/240 min x 60 gtt/mL = X gtt/min X = 25 STEP 6: Round if necessary. STEP 7: Reassess to determine whether the amount to administer makes sense. If the prescription reads 100 ml of 0.9% sodium chloride IV to infuse over 4 hr, it makes sense to administer 25 gtt/min. The nurse should set the manual IV infusion to deliver0.9% sodium chloride IV at 25 gtt/min. Dimensional Analysis STEP 1: What is the unit of measurement to calculate? gtt/min STEP 2: What is the volume needed? 100 mL STEP 3: What is the total infusion time? 4 hr STEP 4: Should the nurse convert the units of measurement? Yes (min does not equal hr) STEP 5: Set up an equation and solve for X. X = Quantity / 1 mL x Conversion (hr) / Conversion (min) x Volume (mL) / Time (hr) X gtt/min = 60 gtt/1 mL x 1 hr/ 60 min x 100 mL/4 hr X = 25 STEP 6: Round if necessary. STEP 7: Reassess to determine whether the amount to administer makes sense. If the prescription reads 100 ml of 0.9% sodium chloride IV to infuse over 4 hr, it makes sense to administer 25 gtt/min. The nurse should set the manual IV infusion to deliver 0.9% sodium chloride IV at 25 gtt/min. 4. A nurse in a pediatric clinic is assessing a toddler at a well-child visit. Which of the following actions should the nurse take? a. Perform the assessment in a head to toe sequence. b. Minimize physical contact with the child initially. c. Explain procedures using medical terminology. d. Stop the assessment if the child becomes uncooperative. Rationale: The nurse should initially minimize physical contact with the toddler, and then progress from the least traumatic to the most traumatic procedures. 5. A nurse is caring for an 18-year-old adolescent who is up-to-date on immunizations and is planning to attend college. The nurse should inform the client that he should receive which of the following immunizations prior to moving into a campus dormitory? a. Pneumococcal polysaccharide b. Meningococcal polysaccharide c. Rotavirus d. Herpes zoster