ATI PEDS TEST A with RATIONALES RATED A+ 2024

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 -answer: increased protein concentration -rationale: increased protein concentration in the spinal fluid is a finding that can indicate bacterial meningitis Tachypnea -a rapid regular breathing patter -this breathing pattern occurs with anxiety, fever, metabolic acidosis, or severe anemia A nurse is preparing to collect a sample from a toddler for a sickle-turbidity test. Which of the following actions should the nurse plan to take -answer: perform a finger stick -rationale The nurse should perform a finger stick on a toddler as a component of the sickle turbidity test. -if the test is positive, hemoglobin electrophoresis is required to distinguish between children who have the genetic trait and children who have the disease Blood pressure range of a toddler -86-118 mmHg systolic -44 to 74 mmHg diastolic - Respiratory rate for a toddler -20-25 breaths per minute Average weight of a toddler -14.5kg (32lbs) Heart rate for a toddler is =80-120 BPM 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 medication should the nurse administer first -epinephrine -the child is most likely experiencing an anaphylactic reaction to cefazolin. According to evidence-based practice, the nurse should first administer epinephrine to treat anaphylaxis. Epinephrine is a beta adrenergic agonist that stimulates the heart, causes vasoconstriction of blood vessels in the skin and mucous membranes, and triggers bronchodilation in the lungs 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. Therefore, the child comprehends time best when it is explained to them in relation to an event they are familiar with, such as eating. A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction? -flank pain -the nurse should recognize that flank pain is caused by the breakdown of RBC's and is an indication of a hemolytic reaction to the blood transfusion An allergy to neomycin with an anaphylactic reaction is a contraindication for receiving the MMR vaccine. Clients who have a sever allergy to eggs or gelatin should not receive the vaccine A nurse in an emergency department is caring for a school-age child who is experiencing an anaphylactic reaction. Which of the following is a priority action by the nurse? -Administer epinephrine IM to the child -When using the urgent vs. nonurgent approach to client care, the nurse should determine the priority action is administering epinephrine IM to the child. During an anaphylactic reaction, histamine release causes bronchoconstriction and vasodilation. This is an emergency because ultimately this causes decreased blood return to the heart