ATI RN
RN ATI Comprehensive Assessment Exam Retake 2023 V2 Questions
Extract:
Question 1 of 5
A community health nurse is working with a family that is struggling to adapt following the loss of a family member. Which of the following actions should the nurse take first?
Correct Answer: B
Rationale: The correct answer is B: Determine the roles of individual family members. This is the first step because it helps the nurse understand the dynamics within the family, identify strengths and weaknesses, and assess how each member is coping with the loss. By determining roles, the nurse can tailor interventions to address specific needs and promote effective communication and support. Referring the family to a grief support group (
A) may be helpful later, but understanding the family dynamics comes first. Encouraging tasks assignment (
C) and establishing a routine (
D) are important, but understanding roles is foundational for effective intervention.
Question 2 of 5
A community health nurse is working with a family that is struggling to adapt following the loss of a family member. Which of the following actions should the nurse take first?
Correct Answer: B
Rationale: The correct answer is B: Determine the roles of individual family members. This is the first step because it helps the nurse understand the dynamics within the family, identify strengths and weaknesses, and assess how each member is coping with the loss. By determining roles, the nurse can tailor interventions to address specific needs and promote effective communication and support. Referring the family to a grief support group (
A) may be helpful later, but understanding the family dynamics comes first. Encouraging tasks assignment (
C) and establishing a routine (
D) are important, but understanding roles is foundational for effective intervention.
Extract:
Nurses Notes
Today
0800:
Client reports not feeling well with headache, body aches, and chills. Left breast red and tender with swollen, tender lymph nodes in the left axilla. Incision edges well approximated without erythema or drainage. Small amount of lochia rubra noted.
0830
Provider notified of findings. Prescriptions received
Question 3 of 5
For each potential assessment finding, click to specify if the assessment finding is consistent with mastitis or endometritis. Each finding may support more than 1 disease process.
Correct Answer: B: Mastitis; A, C, D: Both
Rationale: The correct answer is B: Painful, tender breast for mastitis. Mastitis is an infection of the breast tissue, causing pain and tenderness. Foul-smelling lochia can be consistent with both mastitis and endometritis, as it indicates infection. Temperature and chills are non-specific findings that can be present in both mastitis and endometritis. In summary, the painful, tender breast is a specific finding for mastitis, while foul-smelling lochia, temperature, and chills can be seen in both conditions due to the presence of infection.
Extract:
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
The nurse is initiating the client's plan of care. Which of the following interventions should the nurse plan to implement? Select all that apply
Correct Answer: A, B, C, D, E, F
Rationale: The correct interventions for the nurse to implement are A, B, C, D, E, and F. A low-stimulation environment helps promote healing and reduce stress. Bed rest may be necessary for certain conditions. Antihypertensive medication is crucial for managing high blood pressure. Betamethasone may be prescribed for various conditions. Monitoring intake and output is essential for assessing fluid balance. Obtaining a 24-hr urine specimen helps evaluate kidney function.
Choices G is incorrect as performing vaginal examinations every 12 hours is not a routine nursing intervention and may be invasive and unnecessary in many cases.
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 5 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). Heart failure and seizures are commonly associated with severe preeclampsia, a serious pregnancy complication characterized by high blood pressure and organ damage. In severe cases, preeclampsia can lead to heart failure due to the increased strain on the heart and seizures due to cerebral edema. Placental abruption (
A), hypoglycemia (
B), and cervical insufficiency (
D) are not directly related to the client's risk in this scenario. Placental abruption is associated with vaginal bleeding, hypoglycemia with low blood sugar levels, and cervical insufficiency with premature dilation of the cervix.