ATI RN
Multi Dimensional Care | Exam | Rasmusson
1. An area of erythema on the child’s skin is being assessed by the nurse. The nurse presses down on the area, and the area becomes white. What time does the nurse document for this finding?
- A. Non-blanching
- B. Blanching
- C. Redness
- D. Warmth
Correct answer: Blanching
Rationale:
2. Which action demonstrates secondary prevention?
- A. Screening for early signs of disease
- B. Providing rehabilitation services
- C. Administering medications
- D. Providing health education
Correct answer: A
Rationale: The correct answer is A: Screening for early signs of disease. Secondary prevention involves activities that aim to detect health issues early to provide timely treatment. Screening for early signs of disease falls under secondary prevention as it helps identify diseases in their early stages, allowing for prompt intervention and management.
3. A client in labor is receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion?
- A. Urine output of 20 ml/hr.
- B. Montevideo units constantly at 300 mm Hg.
- C. FHR pattern showing absent variability.
- D. Contractions occurring every 5 minutes and lasting 30 seconds.
Correct answer: Montevideo units constantly at 300 mm Hg.
Rationale: Montevideo units measure the strength and frequency of contractions during labor. A consistent Montevideo units reading of 300 mm Hg or higher is indicative of effective uterine contractions. In this scenario, an increase in the rate of oxytocin infusion may be warranted to further augment contractions and promote progress in labor. The other options, such as low urine output, absent variability in fetal heart rate, and short contractions, do not directly correlate with the need for an increase in oxytocin infusion rate.
4. A healthcare professional is assessing a child who has nephrotic syndrome. Which of the following findings should the healthcare professional expect?
- A. Hypotension
- B. Hyperglycemia
- C. Facial edema
- D. Weight gain
Correct answer: D
Rationale: In nephrotic syndrome, there is increased permeability of the glomerular filtration barrier, leading to protein loss in the urine. This results in hypoalbuminemia, causing fluid retention and edema. Therefore, weight gain due to fluid retention is a common finding in children with nephrotic syndrome.
5. A nurse is planning a menu for a client with a folic acid deficiency anemia. Which food should the nurse recommend that is high in folate?
- A. 4 slices of roast beef
- B. ½ cup of asparagus
- C. 1 cup part-skim mozzarella cheese
- D. ¼ cup of olives
Correct answer: B
Rationale: The correct answer is B: ½ cup of asparagus. Asparagus is high in folate, making it a suitable recommendation for clients with folic acid deficiency anemia. Folate is essential in the production of red blood cells, which is crucial in managing anemia. Choices A, C, and D do not contain as much folate as asparagus and are not the best options for addressing a folic acid deficiency anemia.
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