ATI RN
VATI ATI Comprehensive Predictor 2023 Questions
Question 1 of 5
A nurse is giving discharge instructions to a client who has a new ileostomy. The nurse should recognize that the teaching has been effective when the client states,
Correct Answer: B
Rationale:
Correct
Answer: B: My stoma will drain liquid fluid continuously.
Rationale: The correct answer is B because an ileostomy typically drains liquid stool continuously due to the location in the small intestine where liquid waste is collected. This statement indicates an understanding of the expected output from the stoma.
Incorrect
Choices:
A: My stoma size will stay the same, even after it has healed - Incorrect as the stoma size may change during the healing process.
C: I will change my pouch system every 2 weeks - Incorrect as pouch systems need to be changed more frequently, usually every few days to prevent leakage and skin irritation.
D: I will ensure that my medications are enteric coated - Incorrect as this statement does not directly relate to stoma care and management.
Question 2 of 5
A nurse is caring for a group of clients. Which of the following clients should the nurse assess first?
Correct Answer: B
Rationale: The correct answer is B. The nurse should assess the client with abdominal pain and vomiting coffee-ground emesis first because this symptom indicates potential upper gastrointestinal bleeding, which is a medical emergency requiring immediate attention to prevent further complications such as hypovolemic shock or organ damage. Assessing this client first is crucial to initiate prompt intervention.
Choice A is not the priority as the client with heart failure experiencing shortness of breath while ambulating may indicate worsening heart failure but is not immediately life-threatening.
Choice C, a client with benign prostatic hyperplasia unable to urinate, requires assessment and intervention but is not as urgent as the client with potential upper gastrointestinal bleeding.
Choice D, a client with green drainage from the T-tube post-cholecystectomy, may indicate a bile leak which needs monitoring but is not as urgent as the client with signs of upper gastrointestinal bleeding.
Question 3 of 5
A nurse is caring for a client who is nulliparous and in the first stage of labor. The last internal assessment revealed 100% cervical effacement with 5 cm of dilatation. At the end of the last contraction, the nurse observes a large gush of fluid coming out of the client's perineal area. Which of the following is a priority action by the nurse?
Correct Answer: C
Rationale: The correct answer is C: Check the FHR. The priority action for the nurse is to assess the fetal heart rate (FHR) to ensure the well-being of the baby. The sudden gush of fluid could indicate rupture of membranes, which may lead to cord prolapse or fetal distress. Monitoring the FHR helps in determining the baby's status and immediate interventions if needed. Performing another internal exam (
A) may increase the risk of infection. Notifying the provider (
B) is important but assessing the baby's well-being comes first. Obtaining a pH test of the fluid (
D) can be done later if needed.
Question 4 of 5
A nurse is providing teaching to the parent of a 6-month-old infant who is teething and having difficulty sleeping. Which of the following instructions should the nurse include?
Correct Answer: C
Rationale: Acetaminophen is safe and effective for teething pain, aiding sleep. Aspirin risks Reye's syndrome, amber necklaces pose a choking hazard, and benzocaine can cause methemoglobinemia.
Question 5 of 5
A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings indicates a possible transfusion reaction?
Correct Answer: A
Rationale:
Correct
Answer: A (Temperature of 38.3°
C)
Rationale:
1. Elevated temperature (>1°C increase) is a common sign of a transfusion reaction.
2. It can indicate an immune response or bacterial contamination in the blood product.
3. Monitoring temperature is crucial for early detection of transfusion reactions.
4. Other vital signs (heart rate, blood pressure, oxygen saturation) may remain stable initially.
5. Prompt action is needed to prevent serious complications.
Summary:
B: Heart rate and blood pressure are within normal range and may not indicate a transfusion reaction.
D: Oxygen saturation is also within normal limits and not specific to a transfusion reaction.
E, F, G: These options are not provided, but an elevated temperature is a key indicator to monitor during a blood transfusion.