a nurse is assessing a client with pancreatitis which of the following findings should the nurse look for
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN

1. A nurse is assessing a client with pancreatitis. Which of the following findings should the nurse look for?

Correct answer: B

Rationale: The correct answer is B: Abdominal pain. Abdominal pain, often severe, is a hallmark sign of pancreatitis. Other common symptoms include nausea, vomiting, and tenderness in the abdomen. Choices A, C, and D are incorrect because increased appetite, weight gain, and elevated blood pressure are not typically associated with pancreatitis. Therefore, the nurse should primarily focus on assessing for abdominal pain in a client with suspected pancreatitis.

2. A nurse is caring for a newborn with hyperbilirubinemia. Which of the following interventions should be taken during phototherapy?

Correct answer: A

Rationale: During phototherapy for a newborn with hyperbilirubinemia, it is crucial to maintain an eye mask over the newborn's eyes. The purpose of the eye mask is to protect the infant's eyes from potential damage caused by the intense light used in phototherapy. While feeding the newborn frequently and monitoring temperature are essential aspects of newborn care, they are not specific to phototherapy. Administering vitamin K is important for newborns to prevent bleeding disorders but is not directly related to phototherapy for hyperbilirubinemia.

3. A healthcare provider is caring for a patient and realizes they administered the wrong medication. What action should the healthcare provider take first?

Correct answer: C

Rationale: The healthcare provider should first assess the patient to determine if any harm has occurred as a result of the medication error. Checking the patient's condition takes precedence as it allows for immediate intervention if necessary. Notifying the provider (choice A) can come later once the patient's condition is assessed. Reporting to the risk manager (choice B) and completing an incident report (choice D) are important steps but should follow the initial assessment of the patient to ensure timely and appropriate actions are taken.

4. A nurse is planning care for a client with a sealed radiation implant. Which intervention should the nurse implement?

Correct answer: B

Rationale: The nurse should wear a dosimeter badge to monitor radiation exposure when caring for a client with a sealed radiation implant.

5. A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which of the following should the nurse assess for?

Correct answer: C

Rationale: In a client with COPD, the nurse should assess for the use of accessory muscles. This is important because COPD can lead to increased work of breathing, causing the client to engage accessory muscles to help with respiration. Assessing for the use of accessory muscles provides crucial information about the client's respiratory effort. Respiratory rate (Choice A) is a standard assessment parameter but may not specifically indicate the severity of COPD. Chest pain (Choice B) is not typically associated with COPD unless there are complicating factors. Oxygen saturation (Choice D) is essential to monitor in COPD clients, but assessing for the use of accessory muscles takes priority as it directly reflects the client's respiratory status in COPD.

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