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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. Because the census is currently low in the Obstetrics (OB) unit, one of the nurses is sent to work on a medical-surgical unit for the day, or until the OB unit becomes busy. Which client assessment is best for the charge nurse to assign to the OB nurse?
- A. An adult who had a colon resection yesterday and has an IV.
- B. An older adult who has a fever of unknown origin.
- C. A woman who had an acute brain attack (stroke, CVA) 6 hours ago.
- D. A teenager with a femoral fracture who is in traction.
Correct answer: A
Rationale: The OB nurse is most experienced in postoperative care, making the client who had a recent colon resection the most suitable assignment. This client would require care that aligns closely with the expertise and skills of the OB nurse, ensuring optimal patient outcomes and effective utilization of nursing resources.
3. A male client is admitted to the neurological unit. He has just sustained a C-5 spinal cord injury. Which assessment finding of this client warrants immediate intervention by the nurse?
- A. Is unable to feel sensation in the arms and hands.
- B. Has flaccid upper and lower extremities.
- C. Blood pressure is 110/70 and the apical pulse is 68.
- D. Respirations are shallow, labored, and 14 breaths/minute.
Correct answer: D
Rationale: Respirations that are shallow, labored, and at 14 breaths/minute indicate potential respiratory compromise, which is a critical situation requiring immediate intervention to maintain adequate oxygenation and prevent respiratory failure.
4. A client with myelogenous leukemia is receiving an autologous bone marrow transplantation (BMT). What is the priority intervention that the nurse should implement when the bone marrow is repopulating?
- A. Administer sargramostim (Leukine, Prokine).
- B. Infuse PRBC and platelet transfusions.
- C. Give parenteral prophylactic antibiotics.
- D. Maintain a protective isolation environment.
Correct answer: D
Rationale: Maintaining a protective isolation environment is crucial during the repopulation of bone marrow post-transplant to reduce the risk of infections. The client's immune system is compromised during this period, making them highly susceptible to infections. By implementing protective isolation measures, the nurse can help prevent exposure to pathogens, safeguarding the client's health and supporting the success of the transplantation.
5. When evaluating a client's understanding of wearing a Holter monitor, which statement made by the client would indicate to the nurse that the client understands the procedure?
- A. I must record any symptoms occurring with my activity.
- B. I am not looking forward to staying in bed for 24 hours.
- C. I really am dreading the frequent blood drawing.
- D. I know that I shouldn't get close to my microwave oven.
Correct answer: A
Rationale: The correct answer is A. Recording symptoms that occur with activity is crucial when wearing a Holter monitor. This information helps in correlating symptoms with cardiac events, aiding in the diagnosis and treatment of the client's condition. The client's understanding of this aspect demonstrates comprehension of the procedure and its purpose.
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