ATI RN
RN ATI Comprehensive Assessment Exam Retake 2023 V2 Questions
Extract:
Question 1 of 5
A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take?
Correct Answer: C
Rationale: The correct answer is C: Protect the IV bag from exposure to light. Nitroprusside is light-sensitive and exposure to light can cause it to degrade, leading to potential harm to the patient. The nurse should take this action to maintain the integrity of the medication. Monitoring blood pressure every 2 hours (choice
A) is important but not specific to nitroprusside administration. Attaching an inline filter to the IV tubing (choice
B) may be unnecessary for nitroprusside administration. Keeping calcium gluconate at the client's bedside (choice
D) is not directly related to the administration of nitroprusside.
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 2 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:
Question 3 of 5
A nurse is planning care for a client who has acute appendicitis. Which of the following actions should the nurse plan to take?
Correct Answer: C
Rationale:
Correct Answer: C - Keep the client on NPO status
Rationale: In acute appendicitis, the client may require urgent surgery to remove the inflamed appendix. Keeping the client NPO (nothing by mouth) is essential to avoid potential complications during surgery, such as aspiration of stomach contents. This action also helps prevent delays in the surgical intervention and minimizes the risk of infection.
Incorrect
Choices:
A: Placing the client's head of bed flat can increase intra-abdominal pressure and worsen the client's condition.
B: Applying heat to the client's abdomen can exacerbate inflammation and may mask the symptoms, delaying appropriate treatment.
D: Administering a laxative can be dangerous as it may cause the appendix to rupture due to increased pressure from fecal matter.
Question 4 of 5
A nurse is performing a neurological examination on a client as part of a complete physical assessment. The nurse should identify that cranial nerve XI is intact when the client performs which of the following actions?
Correct Answer: A
Rationale: The correct answer is A: Shrugs his shoulders. Cranial nerve XI, also known as the spinal accessory nerve, innervates the trapezius and sternocleidomastoid muscles responsible for shoulder shrugging. By asking the client to shrug his shoulders against resistance, the nurse can assess the integrity of cranial nerve XI. Sticking the tongue out (choice
B) involves cranial nerve XII, frowning symmetrically (choice
C) involves cranial nerve VII, and identifying a sour taste (choice
D) involves cranial nerve IX and VII. These actions do not assess cranial nerve XI.
Question 5 of 5
A charge nurse is monitoring a newly licensed nurse who is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following statements by the newly licensed nurse indicates an understanding of the procedure?
Correct Answer: A
Rationale: The correct answer is A: "I will hang a new bag of TPN and IV tubing every 24 hours." This statement indicates an understanding of the proper procedure for TPN administration. TPN solutions are typically changed every 24 hours to reduce the risk of bacterial contamination. By changing the TPN bag and tubing daily, the nurse is following best practice guidelines to maintain the sterility and integrity of the TPN infusion, ultimately reducing the risk of infection for the client.
Choices B, C, and D are incorrect:
B: "I will obtain the client's weight every other day." While monitoring the client's weight is important for assessing fluid status and nutritional needs, it is not directly related to the procedure of administering TPN.
C: "I will monitor the client's blood glucose level every 8 hours." Monitoring blood glucose levels is important in clients receiving TPN, but the frequency of monitoring can vary depending on the client's condition and the healthcare provider's orders. It