the nurse performs a physical assessment of a newborn it is most important for the nurse to report which of the following findings
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 4

1. During a physical assessment of a newborn, which of the following findings should the nurse prioritize reporting?

Correct answer: A

Rationale: The correct answer is A. A head circumference of 40 cm is abnormally large for a newborn and could indicate conditions like hydrocephalus or other abnormalities, making it a crucial finding to report. Choices B, C, and D are within normal parameters for a newborn and do not pose immediate concerns. Chest circumference of 32 cm is a normal finding. Acrocyanosis and edema of the scalp are common in newborns due to physiological adaptations. A heart rate of 160 bpm and respirations of 40/min may be within the normal range for a newborn.

2. After a pericardiocentesis, what interventions should the nurse implement?

Correct answer: D

Rationale: After a pericardiocentesis, the nurse should implement multiple interventions to monitor the client's condition closely. Monitoring vital signs every 15 minutes for the first hour is crucial to detect any immediate changes that may indicate complications. Evaluating the client's cardiac rhythm is important to identify any arrhythmias that may occur due to the procedure. Recording the amount of fluid removed is essential to calculate fluid balance and ensure accurate monitoring of the client's status. Therefore, all the interventions mentioned are necessary to detect and manage any potential issues post-pericardiocentesis. Choices A, B, and C are all essential components of post-procedural care and should be implemented to ensure the client's safety and well-being.

3. Clinitest is used in testing the urine of a client for glucose. Which of the following, if committed by a nurse, indicates an error?

Correct answer: C

Rationale: When conducting a Clinitest for testing urinary glucose levels, it is essential to add the correct amounts of urine and Clinitest reagent as instructed. Adding more water than urine could dilute the sample, leading to inaccurate test results. It's important to follow the correct ratio of drops specified in the instructions for an accurate reading. Choice A is incorrect as the specimen should be collected before meals for accurate results. Choice B is incorrect as it should be the Clinitest tablet, not the clingiest tablet. Choice D is incorrect as the statement is incomplete and lacks clarity.

4. Which risk factor would the nurse expect to find in the client diagnosed with pancreatic cancer?

Correct answer: C

Rationale: The correct answer is C: Chronic alcoholism. Chronic alcoholism is a significant risk factor for pancreatic cancer as alcohol has a damaging effect on the pancreas. Chewing tobacco (choice A) is associated with oral and throat cancers, not specifically pancreatic cancer. A low-fat diet (choice B) is generally considered a healthier choice and not a direct risk factor for pancreatic cancer. Exposure to industrial chemicals (choice D) may be linked to other types of cancers but is not a major risk factor for pancreatic cancer.

5. The client diagnosed with diabetes mellitus type 2 is admitted to the hospital with cellulitis of the right foot secondary to an insect bite. Which intervention should the nurse implement first?

Correct answer: A

Rationale: Administering intravenous antibiotics is the priority intervention in this situation. Cellulitis is a bacterial infection that can spread rapidly, especially in individuals with diabetes. Immediate antibiotic therapy is crucial to prevent the infection from worsening and causing serious complications. Applying warm moist packs, elevating the foot, and teaching the client about skin and foot care are important interventions but should come after initiating antibiotic treatment to address the underlying infection.

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