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. The nurse is preparing a teaching care plan for the client diagnosed with nephritic syndrome. Which intervention should the nurse include?
- A. Discontinue the use of steroid therapy immediately if symptoms develop.
- B. Take diuretics as needed to treat the dependent edema in ankles.
- C. Increase the intake of dietary sodium every day to decrease fluid retention.
- D. Report any decrease in daily weight during treatment to the healthcare provider.
Correct answer: D
Rationale: The correct answer is D. Reporting a decrease in daily weight is crucial when managing nephritic syndrome as it can indicate worsening of the condition or dehydration. It is essential to monitor weight changes closely to assess the effectiveness of treatment and the client's fluid status. Choice A is incorrect because discontinuing steroid therapy abruptly can lead to complications; gradual tapering is usually recommended. Choice B is incorrect as diuretics should be taken as prescribed by the healthcare provider to manage fluid retention. Choice C is also incorrect because increasing dietary sodium can exacerbate fluid retention, which is counterproductive in nephritic syndrome.
3. A client has been given instructions about ferrous sulfate. Which statement made by the client would indicate the client needs further education?
- A. I will take this medication on an empty stomach.
- B. I will take the morning dose 1 hour before breakfast.
- C. I will need to avoid taking this medication with coffee.
- D. I will take antacids if needed, 2 hours after I take ferrous sulfate.
Correct answer: A
Rationale: The correct answer is A. Ferrous sulfate should be taken on an empty stomach to improve absorption. Choice A is incorrect as taking the medication with a full glass of milk would impair iron absorption. Choices B, C, and D are all correct statements regarding the administration of ferrous sulfate. Choice B ensures proper timing before breakfast, choice C highlights avoiding coffee due to interference with iron absorption, and choice D correctly suggests taking antacids a few hours after ferrous sulfate to prevent potential interactions.
4. What is the primary goal of care for a client diagnosed with sickle cell anemia?
- A. The client will contact the healthcare provider if feeling unwell.
- B. The client will adhere to the medical regimen.
- C. The client will live as normal a life as possible.
- D. The client will demonstrate understanding of treatments.
Correct answer: C
Rationale: The primary goal of care for a client diagnosed with sickle cell anemia is to help them live as normal a life as possible. This involves managing symptoms, preventing crises, and promoting overall well-being. While options A, B, and D are important aspects of care, the ultimate goal is to enhance the client's quality of life and support them in leading a fulfilling and active lifestyle despite their condition.
5. A client with type 1 diabetes is diagnosed with diabetic ketoacidosis and initially treated with intravenous fluids followed by an IV bolus of regular insulin. The nurse anticipates that the practitioner will prescribe a continuous infusion of insulin of:
- A. Novolin L insulin
- B. Novolin R insulin
- C. Novolin N insulin
- D. Novolin U insulin
Correct answer: B
Rationale: The correct answer is Novolin R (Regular insulin) because it is used for continuous infusion to treat diabetic ketoacidosis. Novolin R has a rapid onset of action, making it suitable for this acute situation. Novolin L insulin (Choice A) is not typically used for continuous infusion in diabetic ketoacidosis. Novolin N insulin (Choice C) is an intermediate-acting insulin and is not ideal for rapid correction needed in diabetic ketoacidosis. Novolin U insulin (Choice D) is an ultra-long-acting insulin and is not appropriate for the immediate correction required in this scenario.