ATI RN
ATI RN Fundamentals Online Practice 2023 B Questions
Extract:
Question 1 of 5
A nurse is caring for a patient who has herpes zoster and is inquiring about the use of complementary and alternative therapies.Which of the following actions should the nurse take to reduce the patient’s risk of developing plantar flexion contractures?
Correct Answer: D
Rationale: Applying an ankle-foot orthotic device to the patient's feet can help maintain the foot in a neutral position, thereby reducing the risk of developing plantar flexion contractures.
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 2 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:
Choice A: Implementing airborne precautions is not necessary as the client's symptoms suggest a severe respiratory infection, possibly pneumonia, but not an airborne disease.
Choice B: The client's worsening respiratory distress indicates potential need for intubation and mechanical ventilation to ensure adequate oxygenation.
Choice C: Monitoring blood glucose is important due to the client's diabetes and corticosteroid use, which can elevate glucose levels.
Choice D: Administering prescribed antibiotics like Levofloxacin is critical for treating a likely bacterial infection.
Choice E: Strict hand hygiene is a standard precaution to prevent infection spread.
Choice F: Increasing fluid intake helps thin sputum, aiding respiratory function.
Choice G: There is no indication for chest tube insertion as the pleural effusion is not significant enough.
Extract:
Question 3 of 5
A nurse is administering fluids to a client.Which of the following assessments should the nurse identify as the priority when monitoring for adverse effects?
Correct Answer: A
Rationale: Auscultating lung sounds is the priority when monitoring for adverse effects of administering IV fluids. Fluid overload can lead to pulmonary edema, which would be detected by abnormal lung sounds.
Question 4 of 5
A nurse is educating an older adult client at risk for osteoporosis on starting a regular physical activity program. Which type of activity should the nurse recommend?
Correct Answer: A
Rationale: Walking briskly is a weight-bearing exercise that is essential for maintaining bone mass, which can help to prevent osteoporosis.
Extract:
Nurses’ Notes
• The client reports a sudden onset of chest tightness and difficulty breathing starting approximately 30 minutes ago.
• The client is anxious and visibly distressed, clutching her chest intermittently.
• She has a history of hypertension and diabetes, which are being managed with medication.
• On examination, the client is sitting upright and appears to be in moderate respiratory distress.
• The client mentions feeling lightheaded and reports a slight headache.
• She is sweating profusely and her skin is pale.
• The client denies any recent physical exertion or known exposure to irritants.
Vital Signs
• Temperature: 37.2°C (99.0°F)
• Heart Rate: 104 beats per minute
• Respiratory Rate: 22 breaths per minute
• Blood Pressure: 158/92 mmHg
Physical Examination Results
• The client’s lungs exhibit bilateral wheezing and crackles upon auscultation.
• There is no visible swelling or edema in the extremities.
• The client has a dry cough that is intermittent.
• No cyanosis is noted around the lips or extremities.
• The client’s skin is cool and clammy.
• The client appears slightly disoriented when asked questions.
• There is no sign of trauma or injury.
Question 5 of 5
A 45-year-old female client is admitted to the emergency department with complaints of sudden shortness of breath and chest tightness. She has a history of hypertension and diabetes.Exhibits:A nurse is assessing the client at 0700 hrs. Which of the following actions should the nurse take first? A Initiate a cardiac enzyme panel
Correct Answer: D
Rationale: The client's symptoms of sudden shortness of breath, chest tightness, and anxiety, along with her history of hypertension and diabetes, are concerning for a possible cardiac event. An electrocardiogram (ECG) can provide immediate information about the heart's electrical activity and help identify if the client is experiencing a heart attack or other cardiac event. This should be the first action taken to quickly identify the cause of the client's symptoms and initiate appropriate treatment.