ATI RN
ATI RN Custom Exams Set 4
1. During a physical assessment of a newborn, what finding should the nurse prioritize reporting?
- A. Head circumference of 40 cm
- B. Chest circumference of 32 cm
- C. Acrocyanosis and edema of the scalp
- D. Heart rate of 160 bpm and respirations of 40/min
Correct answer: A
Rationale: The correct answer is A because a head circumference of 40 cm is unusually large for a newborn, which may indicate hydrocephalus or other abnormalities. Reporting this finding is crucial for further evaluation and intervention. Choices B, C, and D are not as concerning during a newborn physical assessment. A chest circumference of 32 cm is within the normal range for a newborn. Acrocyanosis and edema of the scalp are common findings in newborns and usually resolve without intervention. While a heart rate of 160 bpm and respirations of 40/min should be monitored, they are not as critical as an unusually large head circumference.
2. Integrated management for childhood illness is the universal protocol of care endorsed by WHO and is used by different countries worldwide, including the Philippines. In any case that the nurse classifies the child and categorizes the signs and symptoms in the PINK category, you know that this means:
- A. Urgent referral
- B. Antibiotic Management
- C. Home treatment
- D. Outpatient treatment facility is needed
Correct answer: B
Rationale: When a child is classified under the PINK category in the Integrated Management of Childhood Illness (IMCI) guidelines, it signifies the need for antibiotic management. This category indicates severe signs and symptoms requiring immediate antibiotic treatment to address the underlying infection. Choices A, C, and D are incorrect because the PINK category specifically calls for urgent antibiotic management rather than urgent referral, home treatment, or outpatient treatment facility.
3. A nurse is reviewing the laboratory values of a client who is receiving heparin therapy for deep-vein thrombosis. Which of the following values should the nurse report to the provider?
- A. INR 2.0
- B. Platelet count 150,000/mm3
- C. aPTT 60 seconds
- D. WBC count 8,000/mm3
Correct answer: C
Rationale: The correct answer is C: aPTT 60 seconds. An aPTT of 60 seconds is above the therapeutic range for clients on heparin therapy and indicates a risk of bleeding, so it should be reported to the provider. INR of 2.0 is within the therapeutic range for clients on heparin therapy, so it does not require immediate reporting. Platelet count of 150,000/mm3 and WBC count of 8,000/mm3 are within normal ranges and not directly related to heparin therapy, so they do not need to be reported in this context.
4. A client is receiving discharge instructions from a healthcare provider after being prescribed albuterol for COPD. Which statement by the client indicates understanding of the teaching?
- A. Albuterol can increase my blood sugar levels.
- B. Albuterol can decrease my immune response.
- C. I can experience an increase in my heart rate while taking albuterol.
- D. I may develop mouth sores while taking albuterol.
Correct answer: C: "I can experience an increase in my heart rate while taking albuterol."
Rationale: Albuterol is a bronchodilator commonly used to treat conditions like COPD. One of its common side effects is an increase in heart rate (tachycardia) due to its action on beta-2 receptors in the body. This statement by the client demonstrates an understanding of a potential side effect of albuterol, indicating comprehension of the discharge teaching provided by the healthcare provider.
5. Development is best understood as __________.
- A. genetically determined
- B. environmentally influenced
- C. an unsolvable puzzle
- D. a series of complex exchanges between nature and nurture
Correct answer: D
Rationale: The correct answer is D. Development is best understood as a series of complex exchanges between nature (genetic factors) and nurture (environmental influences). This perspective emphasizes the interaction and interplay between genetic predispositions and environmental experiences in shaping an individual's development. Choices A and B are too extreme as they suggest that development is solely determined by genetics or solely influenced by the environment, which is not the case. Choice C is incorrect as development is not viewed as an unsolvable puzzle but rather as a dynamic process influenced by multiple factors.