ATI RN
clinical skills questions Questions
Question 1 of 9
The nurse is caring for a patient receiving peritoneal dialysis. The patient suddenly complains of abdominal pain and chills. The patient’s temperature is elevated. The nurse should
Correct Answer: D
Rationale: The correct answer is D: inform the provider of probable visceral perforation. This is the most urgent action as sudden abdominal pain, chills, and elevated temperature in a patient receiving peritoneal dialysis could indicate a serious complication like visceral perforation, which requires immediate medical attention to prevent further complications. Assessing peritoneal dialysate return (A) may provide some information but does not address the urgent need to address a potential visceral perforation. Checking the patient's blood sugar (B) and evaluating the patient's neurological status (C) are not priorities in this situation and do not address the potential life-threatening complication of visceral perforation.
Question 2 of 9
A normal glomerular filtration rate is
Correct Answer: B
Rationale: The correct answer is B (80 to 125 mL/min) because this range represents the normal glomerular filtration rate (GFR) for a healthy adult. GFR indicates the rate at which blood is filtered by the kidneys, with 125 mL/min being the average value. Values below 80 mL/min (Choice A) suggest impaired kidney function, while values above 189 mL/min (Choice D) may indicate hyperfiltration or underlying conditions. Choice C (125 to 180 mL/min) falls within the normal range, but the typical average is around 125 mL/min. Thus, choice B is the correct answer as it reflects the standard GFR range for adults.
Question 3 of 9
The most significant clinical finding of acute adrenal crisis associated with fluid and electrolyte imbalance is
Correct Answer: C
Rationale: Step-by-step rationale for the correct answer (C: hyperkalemia): 1. Adrenal crisis leads to adrenal insufficiency, causing decreased cortisol levels. 2. Cortisol plays a crucial role in regulating potassium levels. 3. With decreased cortisol, potassium levels can rise, leading to hyperkalemia. 4. Hyperkalemia can result in life-threatening cardiac arrhythmias. Summary: A: Fluid volume excess is not typical in adrenal crisis. B: Hyperglycemia can be present but is not the most significant finding. D: Hypernatremia is not a typical feature of adrenal crisis.
Question 4 of 9
The critical care nurse is responsible for monitoring the patient receiving continuous renal replacement therapy (CRRT). In doing so, the nurse should
Correct Answer: B
Rationale: Correct Answer: B Rationale: 1. Hemofilter clotting can affect CRRT efficiency. 2. Assessing every 6 hours allows early detection and intervention. 3. Clotting can lead to treatment interruptions or complications. 4. Regular assessment ensures optimal therapy delivery. Other Choices: A: Assessing tubing warmth is not a reliable indicator of CRRT function or complications. C: Covering dialysis lines to protect from light is not a standard practice in CRRT monitoring. D: Using clean technique is not sufficient for vascular access dressing changes; aseptic technique is required for infection prevention.
Question 5 of 9
The nurse is caring for a patient with head trauma who was admitted to the surgical intensive care unit following a motorcycle crash. What is an important assessment that will assist the nurse in early identification of an endocrine disorder commonly associated with this condition?
Correct Answer: D
Rationale: The correct answer is D: Urine osmolality. In head trauma patients, the risk of developing diabetes insipidus (DI) is high due to damage to the posterior pituitary. Monitoring urine osmolality helps identify DI early, as low urine osmolality indicates impaired concentration ability. This is crucial for prompt treatment to prevent dehydration. Choices A and B are important but not specific to endocrine disorders. Choice C is relevant for respiratory assessment, not endocrine disorders.
Question 6 of 9
The nurse is providing insulin education for an elderly patient with long-standing diabetes. A prescription has been written for the patient to take 20 units of insulin glargine at 10 PM nightly. The nurse should instruct the patient that the peak of the insulin action for this agent is
Correct Answer: D
Rationale: The correct answer is D: peakless. Insulin glargine is a long-acting insulin with a smooth, consistent release of insulin over 24 hours, providing a steady level of insulin without a pronounced peak. This characteristic helps in maintaining stable blood glucose levels. Options A, B, and C are incorrect as they refer to peak values that do not apply to insulin glargine.
Question 7 of 9
A patient with long-standing type 1 diabetes presents to the emergency department with a loss of consciousness and seizure activity. The patient has a history of renal insufficiency, gastroparesis, and peripheral diabetic neuropathy. Emergency personnel reported a blood glucose of 32 mg/dL on scene. When providing discharge teaching for this patient and family, the nurse instructs on the need to do which of the following? (Select all that apply.)
Correct Answer: B
Rationale: The correct answer is B: Administer 15 grams of carbohydrate orally for severe episodes of hypoglycemia. In this scenario, the patient is experiencing severe hypoglycemia (blood glucose of 32 mg/dL) leading to loss of consciousness and seizure activity. Administering 15 grams of carbohydrate orally is crucial to rapidly raise the blood glucose levels and address the hypoglycemia. This immediate intervention can help reverse the symptoms and prevent further complications. The incorrect choices: A: Administering glucagon intramuscularly is typically reserved for severe hypoglycemia when the patient cannot take anything by mouth. In this case, oral intake is preferred for faster absorption. C: Discontinuing the insulin pump is not necessary in this situation since the primary concern is treating the acute hypoglycemia. Removing the infusion set can lead to hyperglycemia if not managed properly. D: Increasing home blood glucose monitoring and reporting patterns of hyp
Question 8 of 9
Which of the following are appropriate nursing interventions for the patient in myxedema coma? (Select all that apply.)
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. Administering levothyroxine is crucial in treating myxedema coma as it helps replace the deficient thyroid hormone. 2. This intervention addresses the underlying cause of myxedema coma, which is severe hypothyroidism. 3. Levothyroxine administration can help reverse the symptoms of myxedema coma and improve the patient's condition. Summary of Incorrect Choices: - B: Encouraging high sodium intake is not appropriate as myxedema coma is associated with fluid retention and sodium may exacerbate this. - C: Passive rewarming interventions are not relevant for myxedema coma, as the condition is not typically related to hypothermia. - D: While monitoring airway and respiratory effort is important in general patient care, it is not a specific intervention for myxedema coma.
Question 9 of 9
An individual with type 2 diabetes who takes glipizide has begun a formal exercise program at a local gym. While exercising on the treadmill, the individual becomes pale, diaphoretic, shaky, and has a headache. The individual feels as though she is going to pass out. What is the individual’s priority action?
Correct Answer: B
Rationale: The correct answer is B: Eat something with 15 g of simple carbohydrates. In this scenario, the individual is exhibiting signs of hypoglycemia due to the combination of glipizide (which can lower blood sugar) and exercise. The priority action is to raise blood sugar levels quickly to prevent further complications. Consuming simple carbohydrates, like glucose tablets or juice, will rapidly increase blood sugar levels. This is crucial to prevent the individual from passing out or experiencing more serious consequences. Choice A is incorrect because while hydration is important, it is not the immediate priority in this situation. Choice C is incorrect as going to the first-aid station may waste valuable time when immediate action is needed. Choice D is incorrect as taking another dose of the oral agent can further lower blood sugar levels and worsen the hypoglycemia.