ATI RN
RN ATI Comprehensive Assessment Exam Retake 2023 V2 Questions
Question 1 of 5
A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take?
Correct Answer: C
Rationale: The correct answer is C: Protect the IV bag from exposure to light. Nitroprusside is light-sensitive and can degrade when exposed to light, leading to the formation of toxic metabolites. By protecting the IV bag from light exposure, the nurse ensures the medication's stability and prevents potential harm to the client. Monitoring blood pressure every 2 hours (
Choice
A) is a standard practice for clients receiving nitroprusside but is not the most critical action. Attaching an inline filter to the IV tubing (
Choice
B) is important to prevent particulate matter from entering the client's bloodstream but is not specific to nitroprusside administration. Keeping calcium gluconate at the client's bedside (
Choice
D) is unrelated to nitroprusside administration and is not necessary for this situation.
Extract:
Nurses: Notes
0700
Client is admitted to the unit. They deny suicidal ideations at this time. Client states, 'I am an assistant to a powerful spirit.' Client is poorly groomed and has body odor.
0900:
Called to the client's room. Client states, 'I cannot believe you put me in a room with spiders on the wall,' Client requests immediate transfer to another room.
1200:
Psychiatrist is at the bedside evaluating the client. After history and physical, psychiatrist states that they have diagnosed the client with schizophrenia. Client is to be started on medication and milieu therapy.
Laboratory Results
0700:
Urine drug screen: negative (negative)
History and Physical
0700:
Majority of client's history is obtained from client's parent who presents with client today. According to the parent, client has been acting strangely for a few months. Client's symptoms have been progressively worsening
In the last month, the client has been seeing things that are not present and believes that they are in a close relationship with 'a powerful spirit.' Client has not been bathing regularly for the last few weeks.
Client has no significant health history. Client reports that they do not take illicit substances or drink alcohol. Client's grandparent has a history of schizophrenia.
Vital Signs
0730:
Heart rate 68/min
Respiratory rate 18/min
BP 118/81 mm Hg
Temperature 37.2°C (98.9°F)
Question 2 of 5
For each potential action, click to specify if the action is indicated or contraindicated for the client.
Correct Answer: B, C, D indicated; A, E contraindicated
Rationale:
Correct
Answer: B, C, D indicated; A, E contraindicated
Rationale:
1. B is indicated because asking about hallucinations can help assess the client's mental state.
2. C is indicated as maintaining hygiene is important for the client's well-being.
3. D is indicated to assess and address any suicidal ideation for client safety.
4. A is contraindicated as high TV volume can worsen auditory hallucinations.
5. E is contraindicated as placing near activity room may cause overstimulation and distress.
Extract:
Question 3 of 5
A nurse is preparing to initiate intravenous fluids via infusion pump for a client. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Check the expiration date on the safety inspection sticker of the pump. This is crucial for ensuring the safety and efficacy of the pump. Checking the expiration date ensures that the pump has been recently inspected and is functioning properly, reducing the risk of malfunctions.
A: Obtaining a surge protector is important for electrical safety, but it is not directly related to the specific task of initiating intravenous fluids via an infusion pump.
B: Verifying that the extension cord is ungrounded is unsafe as it increases the risk of electrical hazards.
C: Reporting a frayed cord is essential for patient safety, but proceeding with the infusion without addressing the issue is dangerous.
E, F, G: No information provided.
Extract:
Nurses: Notes
Day 1, 0900:
Client is at 31 weeks of gestation and presents with a severe headache unrelieved by acetaminophen. Client also reports urinary frequency and decreased fetal movement. Client is a G3 P2 with one preterm birth.
Day 1, 0930:
Client reports a constant and throbbing headache and rates it as a 6 on a scale of 0 to 10. Denies visual disturbances. +3 pitting edema in bilateral lower extremities. Patellar reflex 4+ without the presence of clonus. Client reports occasional nighttime leg cramps. Reports three fetal movements within the last 30 min. External fetal monitor applied with a baseline FHR 140/min with occasional accelerations and moderate variability. No uterine contractions noted
Vital Signs
Day 1, 0900:
Temperature (oral) 36.9°C (98.4°F)
Heart rate 72/min
Respiratory rate 16/min
BP 162/112 mm Hg
Oxygen saturation 97% on room air
Day 1, 0930:
Temperature (oral) 37.1°C (98.8°F)
Heart rate 84/min
Respiratory rate 18/min
BP 166/110 mm Hg
Oxygen saturation 99% on room air
Diagnostic Results
Day 1, 1000:
Appearance cloudy (clear)
Color yellow (yellow)
pH 5.9 (4.6 to 8)
Protein 3+ (negative)
Specific gravity 1.013 (1.005 to 1.03)
Leukocyte esterase negative (negative)
Nitrites negative (negative)
Ketones negative (negative)
Crystals negative (negative)
Casts negative (negative)
Glucose trace (negative)
WBC 5 (0 to 4)
WBC casts none (none)
RBC 1 (less than or equal to 2)
RBC casts none (none)
Day 1, 1030:
CBC:
Hemoglobin 18.0 g/dL (12 to 16 g/dL)
Hematocrit 35% (37 to 47%)
Platelets 98,000/mm³ (150,000 to 400,000/mm³)
Question 4 of 5
Drag words from the choices below to fill in each blank in the following sentence. The client is at greatest risk for developing-----and-----
Correct Answer: C,E
Rationale: The correct answer is C, Heart failure, and E, Seizures. The client is at greatest risk for developing heart failure and seizures due to complications during pregnancy. Heart failure can occur due to the increased stress on the heart from pregnancy, especially in individuals with pre-existing heart conditions. Seizures can arise from conditions like eclampsia, which is a severe form of preeclampsia characterized by high blood pressure and organ damage. Placental abruption (
A) is a separation of the placenta from the uterus, not directly related to heart failure or seizures. Hypoglycemia (
B) is low blood sugar levels, which may occur but is not the greatest risk in this scenario. Cervical insufficiency (
D) is the inability of the cervix to stay closed during pregnancy, which is not directly linked to heart failure or seizures.
Extract:
Question 5 of 5
A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make?
Correct Answer: D
Rationale: The correct response is D: "I can give you information about respite care if you are interested." This is the best response because it addresses the son's lack of sleep, which is a common issue for family caregivers. Offering information about respite care can provide the son with the opportunity to take a break and get some rest while ensuring his mother's needs are still met. It shows empathy and support for his situation.
Choice A is incorrect because suggesting a sleeping pill does not address the underlying issue of caregiver stress and may not be the best solution.
Choice B is incorrect as it is a general statement and does not offer any practical help or support.
Choice C, while supportive, does not provide a solution to the son's lack of sleep.