ATI RN
ATI RN Custom Exams Set 3
1. The nurse is preparing the plan of care for a client with fluid volume deficit. Which interventions should the nurse include in the plan of care?
- A. Monitor vital signs every two (2) hours until stable
- B. Weigh the client in the same clothing at the same time daily
- C. Administer mouth care every eight (8) hours
- D. A, B, and C
Correct answer: D
Rationale: The correct interventions to include in the plan of care for a client with fluid volume deficit are monitoring vital signs every two hours until stable, weighing the client in the same clothing at the same time daily, and assessing skin turgor. These interventions are crucial for managing and detecting fluid volume changes. Administering mouth care every eight hours is not directly related to managing fluid volume deficit and does not address the key aspects of monitoring and assessing fluid status, making it an incorrect choice.
2. Which drugs may cause weight gain?
- A. Amphetamines
- B. Steroids
- C. Antibiotics
- D. Nonsteroidal anti-inflammatory drugs
Correct answer: B
Rationale: Steroids are known to cause weight gain as a side effect. Amphetamines, antibiotics, and nonsteroidal anti-inflammatory drugs are not typically associated with weight gain. Amphetamines are more likely to cause weight loss due to their stimulant effects, antibiotics are not commonly linked to weight gain, and nonsteroidal anti-inflammatory drugs usually do not lead to significant weight changes.
3. 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.
4. The nurse understands that which are characteristics of anthrax? Select all that apply.
- A. Cutaneous lesions become a black eschar, Flu-like symptoms are a sign of pulmonary anthrax
- B. Cutaneous lesions become a black eschar
- C. Gastrointestinal anthrax causes blood anthrax
- D. Flu-like symptoms are a sign of pulmonary anthrax
Correct answer: A
Rationale: The correct characteristics of anthrax are that cutaneous lesions become a black eschar, and flu-like symptoms are typical of pulmonary anthrax. Choice B is incorrect as it only covers the cutaneous anthrax characteristic and does not include the flu-like symptoms of pulmonary anthrax. Choice C is incorrect as gastrointestinal anthrax does not cause 'blood anthrax,' and Choice D is incorrect as flu-like symptoms are not associated with gastrointestinal anthrax.
5. A client diagnosed with acute pancreatitis has developed a pseudocyst that ruptures. Which procedure should the nurse anticipate the healthcare provider ordering?
- A. Paracentesis
- B. Chest tube insertion
- C. Lumbar puncture
- D. Biopsy of the pancreas
Correct answer: B
Rationale: The correct answer is B: Chest tube insertion. A chest tube may be needed if a pancreatic pseudocyst ruptures into the pleural space, causing a pleural effusion. Paracentesis (choice A) involves the removal of fluid from the abdominal cavity, not typically indicated for a pancreatic pseudocyst. Lumbar puncture (choice C) is a procedure to collect cerebrospinal fluid from the spinal canal, not relevant to a pancreatic pseudocyst. Biopsy of the pancreas (choice D) is a diagnostic procedure to obtain tissue samples for examination and is not typically done in the context of a ruptured pseudocyst.