ATI RN
ATI RN Fundamentals Online Practice 2023 B Questions
Extract:
Vital Signs (Updated)
• 0700 hrs:
o Blood Pressure (BP): 138/72 mm Hg
o Heart rate: 80/min
o Respirations: 22/min
o Temperature: 38.3°C (101.1°F)
o Oxygen saturation: 90% on room air
• 1100 hrs:
o Blood Pressure (BP): 132/68 mm Hg
o Heart rate: 92/min
o Respirations: 24/min
o Temperature: 39.0°C (102.2°F)
o Oxygen saturation: 88% on room air
• 1500 hrs:
o Blood Pressure (BP): 126/64 mm Hg
o Heart rate: 100/min
o Respirations: 26/min
o Temperature: 39.5°C (103.1°F)
o Oxygen saturation: 86% on room air
Nurses' Notes
• 0700 hrs:
o The client is alert but appears fatigued. Complaints of increased shortness of breath over the past 24 hours. The client has a productive cough with thick, yellow sputum. The client reports feeling increasingly weak and dizzy. Mild confusion is noted, with difficulty maintaining focus during the assessment. The client is diaphoretic and has been experiencing chills intermittently. The skin appears flushed and warm to the touch.
• 1100 hrs:
o The client is visibly distressed and reports worsening dyspnea. The cough is now accompanied by greenish, foul- smelling sputum. The client exhibits increased confusion and disorientation. The skin is cool and clammy, with noticeable pallor. Respiratory effort is labored, with audible wheezing and crackles upon auscultation. The client reports persistent nausea and decreased appetite. There is a noticeable increase in fatigue and lethargy.
• 1500 hrs:
o The client is significantly drowsy and difficult to arouse. Respiratory distress is evident, with use of accessory muscles for breathing. The sputum is now blood-tinged and the cough is frequent and severe. The skin is very pale, with a bluish tinge noted around the lips. The client shows signs of hypotension and rapid pulse. There is an overall decline in mental status, with severe confusion and disorientation. The client complains of severe weakness and generalized body aches.
Medical History
• Diabetes mellitus, well-managed with medication
• Chronic obstructive pulmonary disease (COPD)
• History of hypertension
• No known drug allergies
• Recent travel to an area with known respiratory infections
Diagnostic Results
• 0700 hrs:
o Chest X-ray: Mild infiltrates in the lower lobes
o CBC: Elevated white blood cell count (WBC) 12,000/µL
• 1100 hrs:
o Chest X-ray: Progression of infiltrates with more pronounced consolidation
o CBC: Further elevated white blood cell count (WBC) 15,000/µL; Elevated C-reactive protein (CRP)
• 1500 hrs:
o Chest X-ray: Extensive consolidation with possible pleural effusion
o CBC: High white blood cell count (WBC) 18,000/µL; Elevated CRP; Low hemoglobin (Hb)
Provider's Prescriptions
• 0700 hrs:
o Antibiotic therapy initiated: Levofloxacin 500 mg IV every 24 hours
o Oxygen therapy: 2 L/min via nasal cannula
• 1100 hrs:
o Increased oxygen therapy to 4 L/min via nasal cannula
o Addition of nebulized bronchodilators
• 1500 hrs:
o Oxygen therapy increased to 6 L/min via non-rebreather mask
o Initiation of intravenous corticosteroids
Question 1 of 5
A 60-year-old male client is admitted to the medical-surgical unit. The client is experiencing a worsening of symptoms over the last 24 hours. The client's initial presentation was similar to previous days, but his condition has deteriorated.Exhibits:Based on the evolution of the client’s condition and the provided exhibits, select all that apply. Which of the following actions should the nurse include in the client's care plan?
Correct Answer: B,C,D,E,F
Rationale: The correct answer includes preparing for possible intubation and mechanical ventilation (
B) because the client is experiencing a worsening of symptoms, indicating respiratory distress. Monitoring blood glucose levels frequently (
C) is essential as stress can cause fluctuations in blood sugar levels. Administering IV antibiotics as prescribed (
D) is crucial to treat any infection that may be contributing to the deterioration. Ensuring strict hand hygiene (E) helps prevent the spread of infection. Increasing fluid intake (F) can help thin sputum and ease breathing. Implementing airborne precautions (
A) is not necessary unless specific respiratory infections are suspected. Assisting with chest tube insertion (G) is not indicated based on the information provided.
Extract:
Question 2 of 5
A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse.Which of the following actions should the nurse include?
Correct Answer: B
Rationale:
Correct Answer: B: Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min.
Rationale: Nasal cannula delivers low to moderate levels of supplemental oxygen, typically ranging from 1-6 L/min. Higher flow rates can dry out the nasal passages and increase the risk of oxygen toxicity. This choice aligns with evidence-based practice guidelines for safe oxygen administration.
Incorrect
Choices:
A: Regulating flow rate by aligning with the top of the ball inside the flow meter is not evidence-based and may lead to incorrect oxygen delivery.
C: Keeping the reservoir bag deflated in a partial rebreathing mask is incorrect as the bag should be at least partially inflated to ensure adequate oxygen delivery.
D: Using petroleum jelly to lubricate the patient's nares, face, and lips is not recommended as it can be a fire hazard in the presence of oxygen.
Extract:
Diagnostic Results
Week 1:
Hematocrit (Hct): 42% (Normal range: 37% to 47%)
Hemoglobin (Hgb): 15 g/dL (Normal range: 12 to 16 g/dL)
White Blood Cell (WBC) count: 8,000/mm² (Normal range: 5,000 to 10,000/mm²)
Platelet count: 350,000/mm² (Normal range: 150,000 to 400,000/mm²)
Potassium: 3.7 mEq/L (Normal range: 3.5 to 5 mEq/L)
Week 2:
Hematocrit (Hct): 37% (Normal range: 37% to 47%)
Hemoglobin (Hgb): 12 g/dL (Normal range: 12 to 16 g/dL)
White Blood Cell (WBC) count: 6,000/mm² (Normal range: 5,000 to 10,000/mm²)
Platelet count: 100,000/mm² (Normal range: 150,000 to 400,000/mm²)
Potassium: 3.6 mEq/L (Normal range: 3.5 to 5 mEq/L)
Question 3 of 5
A nurse is caring for a female client. The following diagnostic results have been recorded over two weeks: Complete the following sentence by using the lists of options. The client is at risk for -----------------as evidenced by the-----------------------
Correct Answer: A,E
Rationale: Action to Take: A, E; Potential Condition: B; Parameter to Monitor: E, F.
Rationale: The correct answer is A, E because a decrease in platelet count (E) from 350,000/mm² to 100,000/mm² indicates a risk of bleeding. This is further supported by the decrease in hemoglobin levels (F) from 15 g/dL to 12 g/dL, indicating anemia. Monitoring platelet count (E) and hemoglobin levels (F) will help track the risk of bleeding and anemia. Other choices (C, D, G) are not directly supported by the diagnostic results provided.
Extract:
A nurse is providing care for a patient who has terminal liver cancer.
Question 4 of 5
Which statement from the patient should the nurse recognize as a sign of spiritual distress?
Correct Answer: A
Rationale: The correct answer is A. This statement reflects questioning of personal worth and guilt, indicating spiritual distress. B focuses on external blame, C on familial support, and D on personal control, which are not necessarily signs of spiritual distress. It's important for the nurse to recognize expressions of guilt and self-blame to provide appropriate spiritual care.
Extract:
A client with herpes zoster is inquiring about the use of complementary and alternative therapies for pain management.
Question 5 of 5
Which therapy should the nurse inform the client is contraindicated for their condition?
Correct Answer: D
Rationale: The correct answer is D: Acupuncture. Acupuncture involves inserting thin needles into specific points on the body to alleviate various conditions. However, for some clients with certain medical conditions like bleeding disorders or compromised immune systems, acupuncture can be contraindicated due to the risk of infection or excessive bleeding.
Therefore, the nurse should inform the client that acupuncture is not suitable for their condition.
A: Biofeedback is a non-invasive technique that helps individuals control physiological processes. It is generally safe and not contraindicated for most clients.
B: Aloe is a natural remedy often used for skin conditions or as a dietary supplement. It is generally safe and not contraindicated for most clients.
C: Feverfew is an herb commonly used for migraines and other conditions. While it may interact with certain medications, it is not typically contraindicated for most clients.