Preview Extract
ATI PROCTORED NURSING CARE OF CHILDREN 2019
EXAM A
1. A nurse is creating a plan of care for a school-age child who has heart disease and has developed
heart failure. Which of the following interventions should the nurse include in the plan?
Answer: Provide small, frequent meals for the child. The metabolic rate of a child who has heart
failure is high because of poor cardiac function. Therefore, the nurse should provide small,
frequent meals for the child because it helps to conserve energy.
2. A nurse is teaching the parent of an infant who has a Pavlik harness for the treatment of
developmental dysplasia of the hip. The nurse should identify that which of the following
statements by the parent indicates an understanding of the teaching?
Answer: "I will place my infant's diapers under the harness straps." To prevent soiling of the
harness, the parent should apply the infant's diaper under the straps.
3. 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?
Answer: 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.
4. A nurse is assessing a school-age child immediately following a perforated appendix repair.
Which of the following findings should the nurse expect?
Answer: Absence of peristalsis. The nurse should expect absence of peristalsis immediately
following a perforated appendix repair, until the bowel resumes functioning.
5. A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should
the nurse take?
Answer: Apply topical analgesic cream to the site 1 hr prior to the procedure. The nurse should
apply a topical analgesic to the lumbar site 1 hr prior to the procedure to decrease the adolescent's
pain while the lumbar needle is inserted.
6. 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?
Answer: Epinephrine. This child is most likely experiencing an anaphylactic reaction to the
cefazolin. According to evidence-based practice, the nurse should first administer epinephrine to
treat the 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.
7. A nurse is teaching the parent of a preschooler about ways to prevent acute asthma attacks.
Which of the following statements by the parent indicates an understanding of the teaching?
Answer: "I should keep my child indoors when I mow the yard." The nurse should instruct the
parent to keep the preschooler indoors during lawn maintenance or when the pollen count is
increased. Guarding against exposure to known allergens found outdoors, such as grass, tree, and
weed pollen, will decrease the frequency of the preschooler's asthma attacks.
8. A nurse is proving dietary teaching to the parent of a school-age child who has celiac disease.
The nurse should recommend that the parent offer which of the following foods to the child?
Answer: White rice. The nurse should recommend that the parent offer white rice to the child
because it is a gluten-free food. The nurse should instruct the parent that the child will remain on a
lifelong gluten-free diet and the child should not consume oats, rye, barley, or wheat, and
sometimes lactose deficiency can be secondary to this disease.
9. 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?
Answer: 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, light
headedness, tachycardia, dyspnea, and pallor due to the decreased oxygen- carrying capacity.
10. 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. 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.
11. 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?
Answer: Petechiae on the lower extremities. The 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.
12. A nurse is assessing an infant who has a ventricular septal defect. Which of the following
findings should the nurse expect?
Answer: Loud, harsh murmur. The nurse should expect to hear a loud, harsh murmur with a
ventricular septal defect due to the left-to-right shunting of blood, which contributes to
hypertrophy of the infant's heart muscle.
13. 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?
Answer: 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.
14. A nurse is caring for an adolescent who received a kidney transplant. Which of the following
findings should the nurse identify as an indication the adolescent is rejecting the kidney?
Answer: Serum creatinine 3.0 mg/dL. Creatinine is a byproduct of protein metabolism and is
excreted from the body through the kidneys. An elevated serum creatinine level, therefore, can be
an indication that the kidneys are not functioning. The nurse should identify that the adolescent's
serum creatinine level is higher than the expected reference range of 0.4 to 1.0 mg/dL for an
adolescent and can indicate rejection of the kidney.
15. 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?
Answer: Substernal retractions. When using the airway, breathing, and circulation approach to
client care, the nurse should determine that the priority finding to report to the provider is
substernal retractions. This finding indicates the newborn is experiencing increased respiratory
effort, which could quickly progress to respiratory failure.
16. A hospice nurse is caring for a preschooler who has a terminal illness. The father tells the nurse
that he cannot cope anymore and has decided to move out of the house. Which of the following
statements should the nurse make?
Answer: "Let's 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.
17. A nurse in an emergency department is caring for an adolescent who has severe abdominal pain
due to appendicitis. Which of the following locations should the nurse identify as McBurney's
point?
Answer: The nurse should identify this area of the client's abdomen as McBurney's point. This
area of the right lower quadrant located about two-thirds of the way between the umbilicus and the
client's anterosuperior iliac spine is the area where a client who has appendicitis is most likely to
report pain and tenderness.
18. A nurse is reviewing the laboratory report of a 7 year-old child who is receiving chemotherapy.
Which of the following lab values should the nurse report to the provider?
Answer: Hgb 8.5 g/dL. A child receiving chemotherapy is at risk for anemia due to the
chemotherapy effects on the blood-forming cells of the bone marrow. The development of anemia
is diagnosed through laboratory testing of hemoglobin and hematocrit levels. The nurse should
recognize that a hemoglobin level of 8.5 g/dL is below the expected reference range of 10 to 15.5
g/dL for a 7-year-old child and should be reported to the provider.
19. A nurse is caring for a 15 year-old client who is married and is scheduled for a surgical
procedure. The client asks, "who should sign my surgical consent?" Which of the following
responses should the nurse make?
Answer: "You can sign the consent form because you are married." The nurse should inform the
adolescent that marriage gives adolescents the legal right to consent to surgical procedures and
sign other legal documents that they would not otherwise be able to sign due to their age.
20. A nurse is assessing a 4-year-old child at a well-child visit. Which of the following
developmental milestones should the nurse expect to observe?
Answer: Cuts an outlined shape using scissors. The nurse should recognize that an expected
developmental milestone of a 4-year-old child is using scissors to cut out a shape.
21. A nurse is caring for an infant who has respiratory syncytial virus (RSV). Which of the
following actions should the nurse implement for infection control?
Answer: Have a designated stethoscope in the infant's room. The nurse should initiate droplet
precautions for an infant who has RSV because the virus is spread by direct contact with
respiratory secretions. Therefore, designated equipment, such as a blood pressure cuff and a
stethoscope, should be placed in the infant's room.
22. A nurse in an emergency department is caring for a school-age child who has appendicitis and
rates their abdominal pain as 7 on a scale of 0 to 10. Which of the following actions should the
nurse take? Give morphine 0.05mg/kg IV
Answer: A pain level of 7 on a scale of 0 to 10 is considered severe. The nurse should administer
an analgesic medication for pain relief.
23. 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?
Answer: 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-yearold child. The nurse should expect a child who has early septic shock to have a fever and chills.
24. 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?
Answer: 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.
25. A nurse is caring for a 15 year-old client following a head injury. Which of the following
findings should the nurse identify as an indication that the child is developing syndrome of
inappropriate antidiuretic hormone secretion (SIADH)?
Answer: Mental confusion. A child who has a head injury can develop SIADH as a result of
altered pituitary function, leading to an over secretion of antidiuretic hormone. Over secretion of
antidiuretic hormone leads to a decrease in urine output, hyponatremia, and hypoosmolality due to
overhydration. As the hyponatremia becomes more severe, mental confusion and other neurologic
manifestations such as seizures can occur.
26. 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
Answer: The nurse should expect the following findings in a toddler with spastic (pyramidal)
cerebral palsy:
• Ankle clonus
• Exaggerated stretch reflexes
• Contractures
These are common manifestations of spastic cerebral palsy, which is characterized by increased
muscle tone and stiffness.
27. A nurse in a provider's office if preparing to administer immunizations to a toddler during a
well-child visit. Which of the following actions should the nurse plan to take?
Answer: Withhold the measles, mumps, and rubella (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 a severe allergy to eggs or gelatin should not receive this
vaccine.
28. A school nurse is assessing an adolescent who has scoliosis. Which of the following findings
should the nurse expect?
Answer: 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 Cshaped curvature to the thoracic spine resulting in asymmetry of the ribs, shoulders, hips, or pelvis.
Scoliosis can be the result of a neuromuscular or connective tissue disorder, or it can be congenital
in nature.
29. 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?
Answer: "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.
30. The 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?
Answer: First, the nurse should turn off the IV pump. Next, the nurse should occlude the IV
tubing, and then remove the tape securing the catheter. Last, the nurse should apply pressure over
the catheter insertion site.
31. A nurse is caring for a school-age child who has experienced a tonic-clonic seizure. Which of
the following actions should the nurse take during the immediate postictal period?
Answer: Place the child in a side-lying position. The nurse should place the child in a side-lying
position to prevent aspiration.
32. A nurse is teaching the guardian of a 6-month-old infant about car seat use. Which of the
following statements by the guardian indicates an understanding of the teaching?
Answer: "I should secure the car seat using lower anchors and tethers instead of the seat belt."
Lower anchors and tethers, or the LATCH child safety seat system, should be used to secure an
infant's car seat in the vehicle. This system provides anchors between the front cushion and the
back rest for the car seat. Therefore, if this system is available, the seat belt does not have to be
used.
33. A nurse in an urgent care clinic is assessing an adolescent who has an upper respiratory tract
infection. Which of the following findings should the nurse identify as a manifestation of
pertussis?
Answer: Dry, hacking cough. The nurse should identify that a dry, hacking cough is a
manifestation of pertussis. This disease usually begins with indications of an upper respiratory
tract infection, which includes a dry, hacking cough that is sometimes more severe at night.
34. A nurse is preparing to administer an immunization to a 4-year-old child. Which of the
following actions should the nurse plan to take?
Answer: Administer the immunization using a 24-gauge needle. The nurse should administer an
immunization for a 4-year-old child using a 22- to 25- gauge needle to minimize the amount of
pain the child experiences.
35. 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?
Answer: Speech therapist. The nurse should initiate a referral for a speech therapist for a child
who is postoperative following a cleft palate repair. A child who has a cleft palate will require
speech therapy immediately following the repair to support speech development and future
articulation.
36. A school nurse is preparing to administer atomoxetine 1.2 mg/kg/day PO to a school aged child
who weights 75 lbs. Available is atomoxetine 40 mg/capsule. How many capsules should the nurse
administer per day?
Answer: 1 capsule
37. 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?
Answer: Flank pain. The nurse should recognize that flank pain is caused by the breakdown of
RBCs and is an indication of a hemolytic reaction to the blood transfusion.
38. A nurse in the emergency department is caring for a toddler who has a partial thickness burns
on their right arm. Which of the following actions should the nurse take?
Answer: Cleanse the affected area with mild soap and water. The nurse should wash the affected
area with mild soap and water to remove any loose tissue that could cause infection.
39. A nurse is auscultating the lungs of an adolescent who has asthma. The nurse should identify
the sound as which of the following?
Answer: Tachypnea. The nurse should identify the sound heard during auscultation as tachypnea,
which is a rapid, regular breathing pattern. This breathing pattern often occurs with anxiety, fever,
metabolic acidosis, or severe anemia.
40. A nurse is reviewing the lumbar puncture results of a school-age child suspected of having
bacterial meningitis. Which of the following results should the nurse identify as a finding
associated with bacterial meningitis?
Answer: Increased protein concentration. The nurse should identify that an increased protein
concentration in the spinal fluid is a finding that can indicate bacterial meningitis.
41. 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?
Answer: Respiratory rate 45/min. The 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.
42. A nurse is teaching the parents of a school-age child who has a new diagnosis of osteomyelitis
of the tibia. The nurse should identify that which of the following statements by the parents
indicates an understanding of the teaching?
Answer: "My child will receive antibiotics for several weeks.". The nurse should instruct the
parent that the child will receive antibiotic therapy for at least 4 weeks. Surgery might be indicated
if the antibiotics are not successful.
43. A nurse is providing teaching about social development to the parents of a preschooler. Which
of the following play activities should the nurse recommend for the child?
Answer: Playing dress-up. The nurse should instruct the parents 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.
44. A nurse is reviewing the laboratory report of an infant who is receiving treatment for severe
dehydration. The nurse should identify that which of the following laboratory values indicates
effectiveness of the current treatment?
Answer: Sodium 140 mEq/L. The nurse should identify that a sodium level of 140 mEq/L is
within the expected reference range of 134 to 150 mEq/L and indicates the current treatment
regimen the infant is receiving for dehydration is effective.
45. A nurse is caring for a preschooler who is scheduled for hydrotherapy treatment for wound
debridement following a burn injury. Which of the following actions should the nurse take prior to
the procedure?
Answer: Administer an analgesic to the child. Hydrotherapy for debridement of a wound is an
extremely painful procedure which requires analgesia and/or sedation. When pain is controlled, it
leads to reduced physiological demands on the body caused by stress and decreases the likelihood
of children developing depression and post-traumatic stress disorder.
46. A charge nurse in an emergency department is preparing an in-service for a group of newly
licensed nurses on the clinical manifestations of child maltreatment. Which of the following
manifestations should the charge nurse include as suggestive of potential physical abuse?
Answer: Symmetric burns of the lower extremities. The nurse should include that symmetric
burns to the lower extremities can indicate physical abuse. The patterns are usually characteristic
of the method or object used, such as cigar or cigarette burns, or burns in the shape of an iron.
47. A nurse is caring for a school-age child who in in Buck's traction following a leg fracture 24 hr
ago. Which of the following actions should the nurse take?
Answer: Assess peripheral pulses once every 4 hr. Buck's traction is a type of skin traction that
can be used to immobilize extremities prior to surgery. The nurse should provide frequent
neurovascular checks at least every 4 hr after the first 24 hr of placement in Buck's traction. The
nurse should monitor and report signs of neurovascular impairment in the extremities such as
cyanosis, edema, pain, absent pulses, and tingling.
48. A nurse is planning care for a toddler who has a serum lead level of 4 mcg/dL. Which of the
following actions should the nurse plan to take?
Answer: Schedule the toddler for a yearly rescreening. The nurse should schedule the toddler for a
lead level rescreening in 1 year and educate the family on ways to prevent exposure.
49. A nurse is receiving change-of-shift report on four children. Which of the following children
should the nurse see first?
Answer: 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.
50. A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse
should instruct the parent to apply which of the following to the affected area?
Answer: Zinc oxide. Diaper dermatitis is a common inflammatory skin disorder caused by contact
with an irritant such as urine, feces, soap, or friction, and takes the form of scaling, blisters, or
papules with erythema. Providing a protective barrier, such as zinc oxide, against the irritants
allows the skin to heal.
51. A nurse is caring for a school-age child who is receiving chemotherapy and is severely
immunocompromised. Which of the following actions should the nurse take?
Answer: Screen the child's visitors for indications of infection. A child who is severely
immunocompromised is unable to adequately respond to infectious organisms, resulting in the
potential for overwhelming infection. Therefore, the nurse should screen the child's visitors for
indications of infection.
52. A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of
dehydration. Which of the following findings is the nurses priority?
Answer: Tachypnea. When using the airway, breathing, and circulation approach to client care, the
nurse's priority finding is the toddler's tachypnea. Tachypnea is a result of the kidneys being unable
to excrete hydrogen ions and produce bicarbonate, which leads to metabolic acidosis.
53. A nurse is teaching a school-age child who has a new diagnosis of type 1 diabetes mellitus.
Which of the following statements by the child indicates an understanding of the teaching?
Answer: "I will give myself a shot of regular insulin 30 minutes before I eat breakfast." The child
should administer regular insulin 30 min before meals so that the onset coincides with food intake.
54. 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?
Answer: "Give the infant a pacifier at bedtime." The nurse should inform the parent that protective
factors against SIDS include breastfeeding and the use of a pacifier when the infant is sleeping.
55. The nurse is assessing a school-age child who has peritonitis. Which of the following findings
should the nurse expect?
Answer: Abdominal distension. 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, and restlessness.
56. The nurse is interviewing the parent of an 18-month-old toddler during a well-child visit. The
nurse should identify that which of the following findings indicates a need to assess the toddler for
hearing loss?
Answer: The toddler received tobramycin during a hospitalization 2 weeks ago. The nurse should
identify tobramycin as an aminoglycoside, which is an ototoxic medication that can cause mild to
moderate hearing loss, and should assess the toddler for a hearing impairment.
57. 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?
Answer: "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.
58. A nurse is admitting a school-age child who has Pertussis. Which of the following actions
should the nurse take?
Answer: Initiate droplet precautions for the child. The nurse should initiate droplet precautions for
a child who has pertussis, also known as whooping cough. Pertussis is transmitted through contact
with infected large-droplet nuclei that are suspended in the air when the child coughs, sneezes, or
talks.
59. A nurse is caring for a toddler who is experiencing acute diarrhea and has moderate
dehydration. Which of the following nutritional items should the nurse offer to the toddler?
Answer: Oral rehydration solution. A toddler who has acute diarrhea should consume an oral
rehydration solution to replace electrolytes and water by promoting the reabsorption of water and
sodium. This promotes recovery from dehydration.
60. 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?
Answer: Administer epinephrine IM to the child. When using the urgent vs. nonurgent 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 this causes decreased blood return to the
heart.
