ATI RN
ATI Clinical Exam Questions
Extract:
Nurses’ Notes at 0700hrs
The client appears fatigued and reports a persistent headache. He has been experiencing muscle aches throughout his body. He also complains of a sore throat and has had a fever for the past two days. The client’s skin is warm to the touch and he appears slightly dehydrated.
Vital Signs at 0700hrs
• Temperature: 39.5°C (103.1°F)
• Blood pressure: 128/56 mm Hg
• Heart rate: 112/min
• Respiratory rate: 22/min
• SaO2: 96% on room air
Diagnostic Results at 0700hrs
• Complete blood count shows elevated white blood cells
• Throat culture has been sent to the lab for analysis
• Chest X-ray pending
Question 1 of 5
A nurse is caring for a 45-year-old male client in the emergency department. The client was admitted at 0700hrs with a 2-day history of headache, muscle aches, fever, sore throat, and fatigue.The nurse is preparing to administer an antibiotic to the client. Which of the following actions should the nurse take? (Select all that apply)
Correct Answer: B,E,F,G
Rationale: The correct actions the nurse should take are to encourage the client to increase fluid intake, monitor the client's temperature every 4 hours, check the client's allergy history before administering the antibiotic, and educate the client about the importance of completing the full course of antibiotics.
Encouraging fluid intake helps maintain hydration and aids in the body's recovery. Monitoring temperature helps assess the client's response to treatment. Checking allergy history is crucial to prevent adverse reactions. Educating the client about completing the full course of antibiotics ensures effective treatment and prevents antibiotic resistance.
Wearing a mask (choice
A) is not necessary for this situation unless the client is suspected of having a contagious respiratory illness. Placing the client in a private room (choice
C) and placing the client on contact precautions (choice
D) are not indicated unless the client is diagnosed with a specific contagious infection, which is not mentioned in the scenario.
Extract:
Nurse's Notes & Physical Examination
• The client arrived in the emergency department with complaints of fatigue, blurred vision, dizziness, and headache for the past two days. They report running out of blood glucose strips and insulin due to financial constraints. The client appears tired, is cooperative, and has a slightly dry mucous membrane. They are oriented to person, place, and time but seem concerned about their health status. The skin is warm and dry to the touch, with no visible rashes or lesions. Heart sounds are regular without murmurs; breath sounds are clear bilaterally. The abdomen is soft with no tenderness upon palpation. The client expresses anxiety about potential falls due to dizziness.
Vital Signs
• Blood Pressure: 120/72 mm Hg
• Temperature: 36.8° C (98.2° F)
• Pulse: 88/min
• Respirations: 20/min
Diagnostic Results
• Blood Glucose: 235 mg/dL (Reference range: 74-106 mg/dL)
• HbA1c: 8.4% (Target for diabetics: <7%)
• Hemoglobin: 14.2 g/dL (12-18 g/dL)
• Hematocrit: 42.6% (37-52%)
• WBC Count: 6000/mm³ (5000-10,000/mm³)
Provider's Prescriptions
• Increase glargine from 20 units to 25 units at bedtime.
• Continue other home medications as prescribed.
Scenario: A nurse is caring for a client admitted to the medical-surgical unit. The exhibits below detail the client's condition at different time points throughout the day. Review the exhibits and determine how the patient's condition evolves and whether it worsens or improves. The initial data is recorded at 0700 hrs, followed by subsequent observations at different times.
Question 2 of 5
Based on the initial assessment and diagnostic results, what is the priority nursing intervention?
Correct Answer: A
Rationale: The correct answer is A: Administer a bolus of IV fluids. The priority nursing intervention is to address any immediate physiological needs identified in the initial assessment and diagnostic results. Administering IV fluids can help stabilize the client's fluid and electrolyte balance, ensuring proper circulation and organ function. This intervention takes precedence over the other options as it directly addresses a critical aspect of the client's condition. Administering insulin (choice
B) may be necessary for managing specific conditions but is not the immediate priority. Oxygen therapy (choice
C) may be beneficial, but if the client is in need of fluid resuscitation, addressing hypovolemia takes precedence. Fall precautions and providing a bedside commode (choice
D) are important for safety but do not address the physiological needs identified in the initial assessment.
Extract:
Nurse's Notes & Physical Examination
• The client is found attempting to climb out of bed, stating, "People are trying to hurt me." They are highly agitated and disoriented, attempting to remove IV lines. The client's behavior is erratic, and they require constant supervision. The skin is now cool and pale, with poor capillary refill. Respirations are labored, and the client is using accessory muscles to breathe. Lung sounds have deteriorated, with coarse crackles heard throughout. The abdomen is firm, and the client expresses significant discomfort. The urinary catheter output has decreased, and urine appears concentrated.
Vital Signs
• Blood Pressure: 100/64 mm Hg
• Temperature: 37.3° C (99.1° F)
• Pulse: 110/min
• Respirations: 28/min
Diagnostic Results
• Hemoglobin: 12.5 g/dL
• Hematocrit: 38.0%
• AST: 52 units/L
• ALT: 49 units/L
Provider's Prescriptions
• Soft wrist restraints if necessary.
• Immediate reassessment and adjustment of care plan.
2100 hrs - Critical Incident
Question 3 of 5
A nurse is providing discharge teaching to a client recently diagnosed with a latex allergy. Which of the following client statements indicates a need for further teaching?
Correct Answer: D
Rationale: The correct answer is D. Latex allergy can be triggered by latex balloons.
Therefore, buying balloons for the son's birthday could potentially expose the client to latex, leading to an allergic reaction. Elastic bandages, dishwashing gloves, and ink pens are typically latex-free alternatives. The other choices are incorrect because they do not involve direct exposure to latex.
Extract:
Nurse's Notes & Physical Examination
• The client has been lying in bed and appears more fatigued than earlier. They complain of increased dizziness and a persistent headache. The nausea has worsened, and the client reports feeling faint upon sitting up. There is noticeable pallor, and the skin feels cool to touch. The client is breathing rapidly and appears anxious, stating that they feel something is not right. Heart rate has increased further, and rhythm remains regular but fast. Lung sounds are now clear bilaterally without diminished areas. The client still requires assistance for ambulation due to unsteadiness.
Vital Signs
• Blood Pressure: 110/68 mm Hg
• Temperature: 36.4° C (97.5° F)
• Pulse: 98/min
• Respirations: 24/min
Diagnostic Results
• Hemoglobin: 13.4 g/dL
• Hematocrit: 40.8%
• Blood Glucose: 245 mg/dL
• Serum Potassium: 4.8 mEq/L (Reference range: 3.5-5.0 mEq/L)
Provider's Prescriptions
• Administer IV fluids at 75 mL/hr.
• Recheck blood glucose level in 2 hours.
• Continue monitoring fluid intake and output.
Scenario :A nurse is caring for a client admitted to the medical-surgical unit. The exhibits below detail the client's condition at different time points throughout the day. Review the exhibits and determine how the client's condition evolves and whether it worsens or improves.
1500 hrs - Follow-Up Assessment
Question 4 of 5
Based on the 1500 hrs assessment, categorize the following actions for the client
| Options | Essential | Nonessential | Contraindicated |
|---|---|---|---|
| Increasing IV fluid rate | |||
| Encouraging the client to sit up without assistance | |||
| Administering antiemetic medication | |||
| Monitoring respiratory rate closely | |||
| Providing reassurance and calming interventions | |||
| Checking electrolyte levels regularly |
Correct Answer:
Rationale: [1, 1, 0]
Increasing IV fluid rate and encouraging the client to sit up without assistance are essential actions based on the assessment. Increasing IV fluid rate helps maintain hydration and support physiological functions, while sitting up without assistance promotes lung expansion and aids in respiratory function. Administering antiemetic medication, monitoring respiratory rate closely, and providing reassurance are important but not essential at this time. Checking electrolyte levels regularly is not mentioned in the scenario and is therefore not relevant.
Extract:
History & Physical (0700hrs)
Date: 06/28/0X
• Client presented to the clinic reporting pelvic pain, dysmenorrhea, dyspareunia, and pain with defecation.
• Vaginal examination reveals fixed, palpable nodules with a retroverted uterus.
• Imaging reveals endometrial lesions on the ovaries, uterosacral ligaments, and round ligaments.
• Endometriosis diagnosed.
Provider's Prescriptions (0700hrs)
• Nafarelin 200 mcg: 1 spray intranasally every morning and 1 spray in the opposite nostril every evening.
Nurse's Notes (0700hrs)
• Client reports adherence to nafarelin regimen without missing doses.
• Client verbalizes irritation in the nasal mucosa.
• Reports feeling better overall with decreased dyspareunia.
• Notes decreased pain during bowel movements.
• Reports decreased pelvic pain and the absence of menstruation last month.
• Mentions experiencing headaches, increased acne, and reduced sex drive since starting treatment.
• Client observes a decrease in breast size.
Scenario:
A nurse is caring for a 32-year-old female client who was recently diagnosed with endometriosis. The client is in the clinic for a follow-up visit after beginning nafarelin treatment.
Setting: Clinic
Question 5 of 5
Which of the following manifestations reported by the client should the nurse identify as a therapeutic effect of the nafarelin? (Select all that apply.)
Correct Answer: B,E
Rationale: The correct answers are B and E. Nafarelin is a gonadotropin-releasing hormone (GnRH) agonist used to treat endometriosis by suppressing estrogen production, thereby reducing symptoms like pain during intercourse (choice
B) and causing missed menstrual cycles (choice E). These are therapeutic effects.
Choices A, C, D, and F are incorrect because CNS manifestations, nasal mucosa changes, breast changes, and dermatological manifestations are not commonly reported therapeutic effects of nafarelin. Thus, options A, C, D, and F can be ruled out.