ATI RN Nursing Care of Children 2023/2024 GRADED A
1. A nurse is assessing a child who is postoperative and received a unit of packed RBCs during a
surgical procedure. Which of the following findings indicates the child is experiencing a
hemolytic transfusion reaction?
Answer: Chills and Flank pain
Rationale: Indicates an incompatibility of the transfused blood product with the clients blood.
The nurse should Identify that the child is having a hemolytic reaction.
2. A nurse is caring for a preschooler who has a terminal illness. The nurse should expect the
preschooler to have which of the following perspectives about death?
Answer: Believes that her own thoughts can cause death
Rationale: The nurse should expect preschoolers to believe that their own thoughts or actions
can cause death, and they might believe that death is a punishment for wrong doing
3. A nurse is assessing an adolescent who has a new diagnosis of anorexia nervosa. Which of the
following findings should the nurse expect?
Answer: Lanugo over the back
Rationale: The nurse should expect an adolescent who has anorexia nervosa to have lanugo
present on the skin as a result of impaired metabolic activity. Other manifestations of anorexia
nervosa include hypothermia, hypotension, and dry skin.
4. 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 recommend which of the following immunizations
prior to moving into a campus dormitory?
Answer: Meningcoccal polysaccharide
Rationale: The meningcoccal polysaccharide immunization is used to prevent infection by
certain groups of meningcoccal bacteria. College freshman, particularly those who live in dorms,
are at an increased risk for meningcoccal disease relative to other persons their age.
5. A nurse is creating a plan of care for a child who has leukopenia secondary to chemotherapy.
Which of the following interventions should the nurse include in the plan?
Answer: Monitor the child for increased temperature
Rationale: Leukopenia places the child at risk of infection; therefore, the nurse should monitor
the child for a fever.
6. A nurse is providing teaching to a 12 year old client who is recovering from an acute episode
of hemophilia A. Which of the following statements should the nurse include in the teaching?
Answer: "You will be able to participate in physical exercises"
Rationale: Physical exercise is important for the maintenance of joint mobility and muscle
strengthening. Participation in non-contact sports and the use of protective equipment such as
knee pads are encouraged, although high-impact athletic activities such as karate should be
avoided.
7. A nurse is caring for a child who has epitaxis. Which of the following actions should the nurse
perform?
Answer: Apply continuous pressure to the child's nose for at least 10 mins
Rationale: The nurse needs to apply continuous pressure for at least 10 mins to help stop
bleeding.
8. A nurse is providing teaching to the guardian of an adolescent. The Guardian reports that the
adolescent sleeps about 10 hr on weekend nights. Which of the responses should the nurse
provide?
Answer: "Adolescents need more sleep due to rapid growth"
Rationale: The nurse should identify that sleeping 10 hrs on the weekend nights is an expected
finding in adolescents, who need more sleep time than other age groups. Common reasons for
the increased need for sleep include stress, busy schedule, and rapid physical growth.
9. A nurse is caring for the family of a preschooler who has a terminal illness. The nurse should
teach the family to expect the preschooler to have which of the following concepts of death?
Answer: People can come back to life after they die.
Rationale: A preschoooler typically views death as temporary and interchangeable with life.
10. A nurse is caring for a child who has a tracheostomy. Which of the following techniques
should the nurse use to suction the child's tracheostomy?
Answer: Remove the catheter while applying intermittent suction
Rationale: The nurse should insert the catheter without suction and then withdraw the catheter
while applying intermittent suction.
11. A nurse is caring for a child who has sickle cell anemia and is experiencing a vaso-occlusive
crisis. Which of the following actions should the nurse take?
Answer: Administer ibuprofen
Rationale: The nurse should administer ibuprofen or acetaminophen for mild to moderate pain.
If pain is not relieved, the nurse should administer an opioid analgesic.
12. A nurse caring for a child who is in the emergency department after ingesting a bottle of
acetaminophen. Which of the following meds should the nurse plan to administer?
Answer: Acetylcysteine
Rationale: Acetylcysteine is the antidote for acetaminophen overdose or poisoning.
13. A nurse caring for a 4 month old child who has acute otitis media and a fever of 38.3C
(101F). Which meds should the nurse administer?
Answer: Amoxicillin
Rationale: A child who has acute otitis media should take an antibiotic to help alleviate the
infection.
14. A nurse is caring for a school aged child who had an arm cast applied 8 hours ago. Which of
the following findings should alert the nurse to a complication related to the casing?
Answer: The child reports tightness at the wrist
Rationale: The nurse should monitor the casted extremity to ensure the swelling does not
increase and cause the cast to become too tight, which can result in impaired circulation. If this
occurs, the child is at risk for compartment syndrome.
15. A nurse is teaching a newly hired nurse about caring for an infant who is postop following
myelomeningocele repair. The nurse should teach the newly hired nurse to monitor the infant for
which of the following complications?
Answer: Hydrocephalus
Rationale: In the surgical repair of the myelomeningocele, the pathway for the cerebral spinal
fluid is altered. Therefore, the infant is at risk of hydrocephalus, and the nurse should monitor the
infant for this condition.
16. A nurse in the emergency department is assessing an infant who recently started taking
digoxin to treat a supraventricular arrhythmia. Which of the following findings should the nurse
identify as an indication of digoxin toxicity?
Answer: Vomiting
Rationale: The nurse should identify that vomiting, especially when unrelated to feedings, is a
manifestation of digoxin toxicity. The nurse should report this finding to the provider
immediately.
17. A nurse is providing teaching to the guardians of an infant who has failure to thrive (FTT).
Which of the following pieces of info should the nurse include in the teaching?
Answer: Add fortified rice cereal to the infant's formula
Rationale: The nurse should inform the guardians that adding fortified rice cereal or vegetable
oil to the infants formula helps promote weight gain
18. A nurse is caring for a 2 year old child who has cystic fibrosis. The nurse is planning to take
the child to the playroom. Which of the activities would be appropriate for the child?
Answer: Building towers with blocks
Rationale: Building towers with blocks is an appropriate activity for a 2 yr old child and
promotes fine motor development. Also, knocking blocks down provides a means of dealing with
the stress of hospitalization.
19. A nurse is reviewing recommended immunizations with the guardian of a 2 month old infant.
Which of the following statements should the nurse make?
Answer: "Your baby can start the pneumococcal vaccine now"
Rationale: The infant can receive the first dose of the pneumococcal vaccine now, with 2
additional doses at 4 months and 12 months of age.
20. A nurse is preparing to assess a 3 month old infant during a well child visit. Which of the
following observations should the nurse expect?
Answer: The infant looks a his hands
Rationale: Infants usually start to look at their hands while lying down or sitting between 12 to
20 weeks of age. Convergence on near objects is usually well established by 3 month of age.
21. A nurse is assessing an infant who was born at 32 weeks gestation and is now 8 months old.
Which of the following developmental ages should the nurse expect the infant to demonstrate?
Answer: 6 months
Rationale: Because the infant was born 8 weeks prematurely, the nurse should use this data to
determine that the infant's setback age is 6 months. Therefore, the nurse should expect the infant
to have achieved the developmental milestones of a 6 month old infant.
22. A nurse is caring for a child who has suspected nephrotic syndrome which of the following
lab values should the nurse expect?
Answer: Serum cholesterol 700 mg/dL
Rationale: A serum cholesterol level of 700 is above the expected reference range. A child who
has nephrotic syndrome will have high serum cholesterol findings because of the increase in
plasma lipids.
23. A nurse is assessing an infant who has acute gastroenteritis. Which of the following findings
should the nurse identify as the priority?
Answer: Capillary refill 5 seconds
Rationale: When using the urgent vs nonurgent approach to client care, the nurse should identify
that the priority finding is a capillary refill of 5 sec. A capillary refill above 4 sec is an indication
of severe dehydration and requires immediate intervention to prevent progression to
hypovolemic shock.
24. A nurse is teaching the parent of a 12 month old infant about nutrition. Which of the
following statements by the parent indicates a need for further teaching?
Answer: "My infant drinks at least 2 qt of skim milk each day"
Rationale: As the infant transitions into toddlerhood, whole milk intake should average 24 to 30
oz per day. Too much milk can affect the child intake of solid foods and result in iron deficiency
anemia. Skim milk is not recommended until after age 2 since it lacks essential fatty acids, which
are needed for growth and development.
25. A nurse is providing teaching to a parent of a preschooler who has tinea capitis. Which of the
following instructions should the nurse include in the teaching?
Answer: Leave the medicated shampoo on the scalp for 5 to 10 mins.
Rationale: The nurse should instruct the parent to use a shampoo made of 2% ketoconazole of
1% selenium sulfide for the treatment of tinea capitis. For the shampoo to be effective, the parent
should leave it on the child's scalp for 5 to 10 mins prior to rinsing.
26. A nurse is providing teaching to the parents of a 4 yr old child about fine motor development.
Which of the following task should the nurse include as an expected finding for this age group?
Answer: Copying a circle
Rationale: The nurse should explain that copying a circle is a skill achieved by the age of 4 yrs.
27. A nurse is reviewing the lab values for a 6 month infant who has acute renal failure. Which of
the following findings should the nurse expect?
Answer: Sodium 125 mEq/L
Rationale: The nurse should expect and infant with acute renal failure to have hyponatremia. A
sodium level of 125 mEq/L is below the expected reference Rance for an infant.
