ATI LPN
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 nurse is in the emergency department monitoring the hydration status of a client receiving oral rehydration. What should the nurse intervene for?
- A. Heart rate 120/min
- B. Urine output 30 mL/hour
- C. Blood pressure 110/70 mmHg
- D. Skin turgor is normal
Correct answer: A
Rationale: A heart rate of 120/min may indicate dehydration or inadequate hydration, prompting the need for IV fluid replacement. Elevated heart rate is a sensitive indicator of dehydration as the body attempts to maintain cardiac output. Urine output of 30 mL/hour is within the normal range (30 mL/hour is the minimum acceptable urine output for an adult). Blood pressure of 110/70 mmHg is within the normal range. Normal skin turgor is a positive sign indicating adequate hydration.
3. A client with newly diagnosed type 2 diabetes is preparing for discharge. Which statement by the client indicates a need for further teaching?
- A. I will take my insulin shots only when my blood sugar is high
- B. I need to follow a balanced diet and exercise regularly
- C. I should monitor my blood sugar levels regularly
- D. I need to take my medication as prescribed by my doctor
Correct answer: A
Rationale: In type 2 diabetes, insulin therapy is typically not the first-line treatment. Patients should follow their prescribed treatment plan, which may or may not include insulin. Taking insulin shots only when blood sugar is high can lead to uncontrolled glucose levels and complications. It is important to adhere to the prescribed medication regimen to manage diabetes effectively.
4. Mrs. Byers tells the nurse that she is very worried because her 2-year-old child does not finish his meals. What should the nurse advise the mother?
- A. Make the child seat with the family in the dining room until he finishes his meal
- B. Provide quiet environment for the child before meals
- C. Do not give snacks to the child before meals
- D. Put the child on a chair and feed him
Correct answer: C
Rationale: Providing a quiet environment can help the child focus on eating.
5. A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse take?
- A. Restrict protein intake to less than 40 g/day
- B. Initiate seizure precautions for the client
- C. Initiate an infusion of 0.9% sodium chloride at 150 mL/hr
- D. Encourage the client to ambulate twice per day
Correct answer: B
Rationale: The correct action for the nurse to take is to initiate seizure precautions for the client. Severe preeclampsia increases the risk of seizures (eclampsia), making it crucial to prioritize the safety of the client. Restricting protein intake (Choice A) is not the priority in this situation as seizure prevention takes precedence. While maintaining hydration is essential, starting an infusion of 0.9% sodium chloride (Choice C) is not the initial action needed for seizure prevention. Encouraging the client to ambulate (Choice D) may not be safe or appropriate considering the severity of preeclampsia and the risk of seizures.
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