ATI RN
ATI Clinical Exam Questions
Extract:
Medication Administration Record
• 1700: Dextrose 5% in 0.45% sodium chloride (D5/0.45% NaCl) at 100 mL/hr
• 1700: Promethazine 25 mg IV bolus every 4 hours PRN for nausea/vomiting
• 1715: Morphine 4 mg IV bolus every 6 hours PRN for pain
• 2115: Acetaminophen 625 mg PO every 6 hours PRN if temperature > 38.6°C (101.5°F)
• Discontinue Morphine (Note: The morphine has not yet been administered as the order is due in the future.)
Nurses' Notes
The client was received from the Post Anesthesia Care Unit (PACU) with initial vital signs recorded. The client is drowsy but arouses to verbal stimuli and is oriented to person, place, and time. The client is able to move all extremities and follow simple commands.
The heart rhythm is normal sinus, bilateral radial and pedal pulses are +2, and capillary refill is less than 2 seconds. Respiratory rate is 18/min with clear lung sounds and oxygen saturation of 96% on 2 L via nasal cannula. Bowel sounds are hypoactive in all four quadrants. The indwelling urinary catheter is draining clear yellow urine. The dressing on the right knee is dry and intact, with no drainage noted.
At 1830, the client was repositioned for comfort with side rails up x2 and the call light within reach. The client remains somewhat lethargic but arouses easily and reports nausea and pain, rating the pain as 6 on a scale from 0 to 10. Metoclopramide 10 mg IV was administered at 1830 for nausea. The client is positioned comfortably with the side rails up and call light within reach.
Physical Examination
• Heart Rate: 88/min
• Respiratory Rate: 18/min
• Blood Pressure: 115/55 mm Hg
• Temperature: 36.4°C (97.5°F)
• Oxygen Saturation: 96% on 2 L via nasal cannula
• General Behavior: Drowsy but arouses easily, somewhat lethargic
• Pain Level: Rated as 6 on a scale from 0 to 10
• Bowel Sounds: Hypoactive in all four quadrants
• Urinary Output: Clear yellow urine from indwelling catheter
• Knee Dressing: Dry and intact with no drainage
Question 1 of 5
A nurse is caring for a client who is 6 hours postoperative following a right knee arthroplasty. The client has been receiving medications and fluids as outlined below.Exhibits Complete the following sentence by selecting the most appropriate action from the choices below: The nurse should first:---------------------,followed by--------------------------------------
Correct Answer: A,B
Rationale: Morphine for pain level 6 is priority, followed by repositioning for comfort. Restraints are not indicated.
Extract:
Question 2 of 5
A nurse is caring for a patient who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider? Which lab value should the nurse report during chemotherapy?
Correct Answer: B
Rationale: Platelet count 50,000/mm3 indicates thrombocytopenia, increasing bleeding risk, requiring reporting. Other values are normal.
Question 3 of 5
A nurse is conducting a class on medication reconciliation. What information should the nurse include in the teaching?,What information should be included in medication reconciliation teaching?
Correct Answer: D
Rationale: Listing medications during admission ensures accurate management. Shift reports, excluding OTC drugs, and skipping discharge reconciliation are incorrect.
Extract:
Nurse's Notes & Physical Examination
• The client has been lying in bed and appears more fatigued than earlier. They complain of increased dizziness and a persistent headache. The nausea has worsened, and the client reports feeling faint upon sitting up. There is noticeable pallor, and the skin feels cool to touch. The client is breathing rapidly and appears anxious, stating that they feel something is not right. Heart rate has increased further, and rhythm remains regular but fast. Lung sounds are now clear bilaterally without diminished areas. The client still requires assistance for ambulation due to unsteadiness.
Vital Signs
• Blood Pressure: 110/68 mm Hg
• Temperature: 36.4° C (97.5° F)
• Pulse: 98/min
• Respirations: 24/min
Diagnostic Results
• Hemoglobin: 13.4 g/dL
• Hematocrit: 40.8%
• Blood Glucose: 245 mg/dL
• Serum Potassium: 4.8 mEq/L (Reference range: 3.5-5.0 mEq/L)
Provider's Prescriptions
• Administer IV fluids at 75 mL/hr.
• Recheck blood glucose level in 2 hours.
• Continue monitoring fluid intake and output.
Scenario :A nurse is caring for a client admitted to the medical-surgical unit. The exhibits below detail the client's condition at different time points throughout the day. Review the exhibits and determine how the client's condition evolves and whether it worsens or improves.
1500 hrs - Follow-Up Assessment
Question 4 of 5
Based on the 1500 hrs assessment, categorize the following actions for the client
| Options | Essential | Nonessential | Contraindicated |
|---|---|---|---|
| Increasing IV fluid rate | |||
| Encouraging the client to sit up without assistance | |||
| Administering antiemetic medication | |||
| Monitoring respiratory rate closely | |||
| Providing reassurance and calming interventions | |||
| Checking electrolyte levels regularly |
Correct Answer:
Rationale: Monitoring respiratory rate (rapid breathing), providing reassurance (anxiety), and checking electrolytes are essential. Antiemetic is helpful but not critical. Increasing fluids without assessment and sitting unassisted (faintness) are contraindicated.
Extract:
Question 5 of 5
A nurse is caring for a patient who is postoperative following abdominal surgery. The nurse discovers a loop of bowel protruding through an opening in the surgical incision. What should the nurse do? What should the nurse do for a protruding bowel?
Correct Answer: C
Rationale: Moistened sterile gauze protects the bowel until surgery. Reinserting, flat positioning, or side positioning are inappropriate.