ATI RN Pediatric Nursing Online Practice 2024 A with Rationales

A nurse in an emergency department is caring for a school-age child who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse? - Administer epinephrine IM Rationale: When using the urgent vs. non-urgent approach to client care, the nurse should determine that 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 it causes decreased blood return to the heart. A nurse in a pediatric emergency department is planning care for an adolescent. Based on the information in the adolescent's medical record, which of the following actions should the nurse plan to take? Select all that apply. - Apply supplemental oxygen Rationale: According to the medical record and chest x-ray report, the adolescent could potentially have a pneumothorax. Also according to the medical record and chest x-ray report, the adolescent's oxygen saturation level is decreasing, which indicates hypoxia. Therefore, the nurse should plan to administer supplemental oxygen. Prepare for chest tube insertion Rationale: According to the medical record and chest x-ray report, the adolescent could potentially have a pneumothorax. A pneumothorax is the presence of air in the pleural cavity, which results in decreased lung expansion. The adolescent could experience dyspnea, tachypnea, tachycardia, hypoxia, and pain. This requires prompt intervention by the provider, such as the placement of a chest tube into the thoracic cavity to remove air and fluid from the pleural space, if present, allowing the lung to re-expand. A nurse in an emergency department is caring for a school-age child who has epiglottitis. Which of the following actions should the nurse take? - Monitor the child's oxygen saturation Rationale: The nurse should monitor the child's oxygen saturation level because the child is experiencing acute respiratory distress and it is necessary to determine if the child is responding to treatment. A nurse is providing teaching about play activities for social development to the guardians of a preschooler. Which of the following play activities should the nurse recommend for the child? - Playing dress-up Rationale: The nurse should instruct the guardians that at the 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 receiving change-of-shift report for 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