RN ATI Comprehensive Assessment Exam Retake 2023 V2 -Nurselytic

Questions 58

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RN ATI Comprehensive Assessment Exam Retake 2023 V2 Questions

Extract:


Question 1 of 5

A nurse is caring for a client who has heart failure. Which of the following manifestations should the nurse expect?

Correct Answer: A

Rationale: The correct answer is A: Crackles in lungs. In heart failure, the heart is unable to effectively pump blood, leading to fluid accumulation in the lungs, causing crackles on auscultation due to pulmonary edema. Decreased thirst (
B) is not typical in heart failure as fluid overload often leads to increased thirst. Poor skin turgor (
C) is more indicative of dehydration. Tachycardia (
D) can occur in heart failure, but it is not specific to this condition.

Question 2 of 5

A nurse is caring for a client who is in active labor and notes the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia?

Correct Answer: C

Rationale: The correct answer is C: Fetal anemia. Fetal bradycardia (baseline <110/min) could indicate fetal distress. Fetal anemia decreases oxygen-carrying capacity, leading to compensatory bradycardia. Maternal hypoglycemia (
A) typically causes fetal tachycardia. Chorioamnionitis (
B) and maternal fever (
D) usually cause fetal tachycardia due to infection. Summarily, fetal anemia is the most likely cause of fetal bradycardia compared to the other options.

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.



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



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)


Question 3 of 5

The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.

Correct Answer: A, B, C, F

Rationale:
Correct Answer: A, B, C, F


Rationale:
A: Urine protein indicates possible preeclampsia, a serious prenatal complication.
B: Decreased fetal activity can signal fetal distress or other issues.
C: Abnormal blood pressure levels may indicate gestational hypertension or preeclampsia.
F: Headaches can be a symptom of preeclampsia, requiring immediate attention to prevent complications.

Incorrect

Choices:
D: Urine ketones usually indicate dehydration or inadequate nutrition, not a prenatal complication.
E: Respiratory rate is not typically used to assess prenatal complications.
G: Gravida/parity information is important but does not directly indicate a prenatal complication.

Extract:


Question 4 of 5

A nurse and an assistive personnel (AP) are assigned a group of clients on the unit. Which of the following clients should the nurse instruct the AP to report to the nurse?

Correct Answer: B

Rationale:
Correct Answer: B


Rationale:
1. Safety: The client with a prescription for compression stockings needs them for circulation and to prevent complications. Not receiving them could lead to health risks.
2. Nursing responsibility: The nurse is accountable for ensuring that prescribed treatments are provided, making it crucial for the AP to report this issue.
3. Collaboration: By reporting to the nurse, the AP allows for timely intervention to address the missed prescription, promoting client safety and well-being.

Summary of other choices:
A: Requesting assistance with the commode is a routine task that the AP can handle independently.
C: Sitting in a chair does not pose a significant risk or indicate a change in condition requiring immediate attention.
D: Consuming all food is a positive sign of appetite and does not warrant immediate reporting unless there are dietary restrictions or concerns documented.

Question 5 of 5

A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching?

Correct Answer: D

Rationale: The correct answer is D: Swelling of the face. At 14 weeks of gestation, facial swelling could indicate preeclampsia, a serious condition characterized by high blood pressure. This finding should be reported to the provider immediately for further evaluation and management to prevent complications.
Incorrect choices:
A: Bleeding gums - Common during pregnancy due to hormonal changes, usually not a significant concern.
B: Faintness upon rising - Could be related to postural hypotension, common in pregnancy but typically not urgent.
C: Urinary frequency - Normal in pregnancy due to increased blood flow to the kidneys, not typically a concerning issue at this stage.

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