ATI RN
clinical skills exam questions Questions
Question 1 of 5
The patient has been admitted to the hospital with nausea and vomiting that started 5 days earlier. Blood pressure is 80/44 mm Hg and heart rate is 122 beats/min; the patient has not voided in 8 hours, and the bladder is not distended. The nurse anticipates a prescription for “stat” administration of
Correct Answer: B
Rationale: The correct answer is B: fluid replacement with 0.45% saline. The patient's symptoms suggest dehydration and hypovolemia, indicated by low blood pressure, elevated heart rate, and lack of urine output. Fluid replacement with isotonic saline would help restore intravascular volume and improve blood pressure. Blood transfusion (A) is not indicated without evidence of significant blood loss. Inotropic agents (C) are used to improve cardiac function, which is not the primary issue in this case. Antiemetics (D) may help with nausea and vomiting but do not address the underlying cause of hypovolemia.
Question 2 of 5
The patient is in the critical care unit and will receive dialysis this morning. The nurse will (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A. By evaluating the morning laboratory results and reporting abnormal results, the nurse can ensure the patient's safety during dialysis by addressing any concerning findings promptly. This step is crucial in monitoring the patient's condition and adjusting the treatment plan as needed. Incorrect choices: B: Administering antihypertensive medications is not directly related to the patient's dialysis procedure and does not address the immediate needs of the patient in the critical care unit. C: While assessing the dialysis access site is important, reporting abnormalities alone may not be sufficient without a comprehensive evaluation of the patient's laboratory results. D: Weighing the patient to monitor fluid status is important in the context of dialysis, but it is not as critical as evaluating laboratory results for immediate intervention.
Question 3 of 5
A patient with type 1 diabetes who is receiving a continuous subcutaneous insulin infusion via an insulin pump contacts the clinic to report mechanical failure of the infusion pump. The nurse instructs the patient to begin monitoring for signs of:
Correct Answer: B
Rationale: The correct answer is B: diabetic ketoacidosis. When an insulin pump fails, the patient may experience a sudden decrease in insulin delivery, leading to a potential rise in blood glucose levels. This can trigger diabetic ketoacidosis, characterized by hyperglycemia, ketosis, and acidosis. Monitoring for signs such as increased thirst, frequent urination, fruity breath odor, and rapid breathing is crucial. Incorrect choices: A: Adrenal insufficiency is not directly related to insulin pump failure. C: Hyperosmolar, hyperglycemic state is more common in type 2 diabetes and typically occurs with extreme hyperglycemia, not sudden pump failure. D: Hypoglycemia is less likely with pump failure due to decreased insulin delivery.
Question 4 of 5
Which of the following is a high-priority nursing diagnosis for both diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome?
Correct Answer: B
Rationale: The correct answer is B: Fluid volume deficient. Both diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome can lead to severe dehydration and electrolyte imbalances. Addressing fluid volume deficiency is crucial to stabilize the patient's condition. Choice A is not the priority as the main concern is the fluid imbalance, not activity intolerance. Hyperthermia (choice C) may be present but is not the primary concern compared to fluid volume deficit. Impaired nutrition (choice D) is not the immediate priority in these emergency situations. In summary, maintaining fluid balance is essential to manage both conditions effectively.
Question 5 of 5
The nurse is caring for a patient with a diagnosis of head trauma. The nurse notes that the patient’s urine output has increased tremendously over the past 18 hours. The nurse suspects that the patient may be developing
Correct Answer: A
Rationale: Rationale: A patient with head trauma may develop diabetes insipidus due to damage to the hypothalamus or pituitary gland, leading to decreased secretion of antidiuretic hormone (ADH). This results in excessive urine output and thirst. Other options are incorrect because: B: Diabetic ketoacidosis is associated with high blood sugar and ketones, not increased urine output. C: Hyperosmolar hyperglycemic syndrome is characterized by extreme hyperglycemia, not increased urine output. D: Syndrome of inappropriate secretion of antidiuretic hormone results in decreased urine output due to excess ADH.