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ATI Medical Surgical Proctored Exam 2019 Quizlet
1. During an admission physical assessment, the nurse is examining a newborn who is small for gestational age (SGA). Which finding should the nurse report immediately to the pediatric healthcare provider?
- A. Heel stick glucose of 65 mg/dL.
- B. Head circumference of 35 cm (14 inches).
- C. Widened, tense, bulging fontanel.
- D. High-pitched shrill cry.
Correct answer: C
Rationale: A widened, tense, bulging fontanel is a critical finding in a newborn as it can indicate increased intracranial pressure. This condition requires immediate attention and intervention to prevent further complications. Monitoring fontanel status is crucial in assessing the newborn's neurological well-being and ensuring early detection of potential issues.
2. A client with schizophrenia is prescribed haloperidol (Haldol). The nurse should monitor the client for which potential side effect?
- A. Tardive dyskinesia.
- B. Orthostatic hypotension.
- C. Photosensitivity.
- D. Hyperglycemia.
Correct answer: A
Rationale: The correct answer is A: Tardive dyskinesia. Haloperidol (Haldol) is an antipsychotic medication that can lead to tardive dyskinesia, a side effect characterized by involuntary, repetitive movements of the face and body. Monitoring for this side effect is crucial to provide timely interventions and prevent further complications.
3. A client with a severe head injury is admitted to the intensive care unit (ICU). Which finding should the nurse report to the healthcare provider immediately?
- A. Urine output of 100 mL/hour.
- B. Intracranial pressure (ICP) of 20 mm Hg.
- C. Respiratory rate of 12 breaths/minute.
- D. Mean arterial pressure (MAP) of 70 mm Hg.
Correct answer: B
Rationale: An Intracranial Pressure (ICP) of 20 mm Hg is at the upper limit of normal and may indicate increased intracranial pressure, which is a critical finding in a client with a severe head injury. Elevated ICP can lead to further brain damage and must be addressed promptly to prevent complications such as herniation. Monitoring and managing ICP are crucial in the care of patients with head injuries in the ICU.
4. A client from a nursing home is admitted with urinary sepsis and has a single-lumen, peripherally-inserted central catheter (PICC). Four medications are prescribed for 9:00 a.m. and the nurse is running behind schedule. Which medication should the nurse administer first?
- A. Piperacillin/tazobactam (Zosyn) in 100 ml D5W, IV over 30 minutes q8 hours.
- B. Vancomycin (Vancocin) 1 gm in 250 ml D5W, IV over 90 minutes q12 hours.
- C. Pantoprazole (Protonix) 40 mg PO daily.
- D. Enoxaparin (Lovenox) 40 mg subq q24 hours.
Correct answer: A
Rationale: In a patient with urinary sepsis, administering Piperacillin/tazobactam first is crucial as it is an antibiotic that directly targets the infection. Addressing the infection promptly is essential to prevent its progression and complications. Vancomycin, Pantoprazole, and Enoxaparin are important medications for the patient's overall treatment plan, but in this scenario, the antibiotic should take precedence due to the urgency of managing the sepsis.
5. A client who delivered a 7-pound infant 12 hours ago is complaining of a severe headache. The client's blood pressure is 110/70, respiratory rate is 18 breaths/minute, heart rate is 74 beats/minute, and temperature is 98.6ยบ F. The client's fundus is firm and one fingerbreadth above the umbilicus. What action should the healthcare team implement first?
- A. Notify the healthcare provider of the assessment findings.
- B. Determine if the client received anesthesia during delivery.
- C. Assign a licensed nurse to reassess the client's vital signs.
- D. Obtain a STAT hemoglobin and hematocrit.
Correct answer: B
Rationale: The correct action to implement first is to determine if the client received anesthesia during delivery. Anesthesia can be a potential cause of postpartum headaches. This information is crucial in assessing and managing the client's condition effectively before considering other interventions. It helps in identifying possible contributing factors to the client's complaint of a severe headache and guides the healthcare team in providing appropriate care and treatment.
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