ATI RN
RN ATI Comprehensive Assessment Exam Retake 2023 V2 Questions
Extract:
Question 1 of 5
A nurse is conducting an initial assessment of a client and notices a discrepancy between the client's current IV infusion and the information received during the shift report. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Compare the current infusion with the prescription in the client's medication record. This is the best course of action as it allows the nurse to verify the accuracy of the IV infusion against the prescribed treatment plan. By cross-referencing the current infusion with the prescription in the client's medication record, the nurse can identify any discrepancies and take appropriate actions to ensure the client's safety and well-being.
Choice A is incorrect because contacting the charge nurse may not provide the necessary information to verify the accuracy of the IV infusion.
Choice B is incorrect as completing an incident report is premature without first verifying the discrepancy.
Choice C is inappropriate and punitive without a proper investigation.
Choices E, F, and G are not provided in the question, so they are irrelevant.
Extract:
Nurses: Notes
0700
Client is admitted to the unit. They deny suicidal ideations at this time. Client states, 'I am an assistant to a powerful spirit.' Client is poorly groomed and has body odor.
0900:
Called to the client's room. Client states, 'I cannot believe you put me in a room with spiders on the wall,' Client requests immediate transfer to another room.
1200:
Psychiatrist is at the bedside evaluating the client. After history and physical, psychiatrist states that they have diagnosed the client with schizophrenia. Client is to be started on medication and milieu therapy.
Laboratory Results
0700:
Urine drug screen: negative (negative)
History and Physical
0700:
Majority of client's history is obtained from client's parent who presents with client today. According to the parent, client has been acting strangely for a few months. Client's symptoms have been progressively worsening
In the last month, the client has been seeing things that are not present and believes that they are in a close relationship with 'a powerful spirit.' Client has not been bathing regularly for the last few weeks.
Client has no significant health history. Client reports that they do not take illicit substances or drink alcohol. Client's grandparent has a history of schizophrenia.
Vital Signs
0730:
Heart rate 68/min
Respiratory rate 18/min
BP 118/81 mm Hg
Temperature 37.2°C (98.9°F)
Question 2 of 5
For each potential action, click to specify if the action is indicated or contraindicated for the client.
Correct Answer: B, C, D indicated; A, E contraindicated
Rationale:
Correct
Answer: B, C, D indicated; A, E contraindicated
Rationale:
1. B is indicated because asking about hallucinations can help assess the client's mental state.
2. C is indicated as maintaining hygiene is important for the client's well-being.
3. D is indicated to assess and address any suicidal ideation for client safety.
4. A is contraindicated as high TV volume can worsen auditory hallucinations.
5. E is contraindicated as placing near activity room may cause overstimulation and distress.
Extract:
Question 3 of 5
A nurse is caring for a client who is near the end of life and is on complete bed rest. The client states that he needs to have a bowel movement, and the nurse offers a bed pan. The client states, 'I've always used the bathroom.' Which of the following responses should the nurse make?
Correct Answer: A
Rationale: The correct answer is A: "Tell me what concerns you have about using a bed pan." This response demonstrates therapeutic communication by acknowledging the client's feelings and allowing them to express their concerns. By understanding the client's perspective, the nurse can address specific fears or preferences related to using the bed pan. This approach promotes client autonomy and dignity.
Choice B is incorrect because it disregards the client's expressed need for a bowel movement while on complete bed rest.
Choice C is inappropriate as it assumes the client is physically able to be ambulated to the bathroom, which may not be the case.
Choice D is incorrect as it is a directive statement that does not address the client's concerns or preferences.
Extract:
Nurses' Notes
0900:
Contractions occurring every 3 to 4 min, lasting 80 to 90 seconds. Client rates pain with contractions as 10 on a scale of 0 to 10 and requests an epidural. Contractions approximately 4 min apart. Vaginal examination reveals cervix dilated 5 cm, 80% effaced, -1 station, vertex presentation. FHR baseline 142/min with moderate variability, IV fluid bolus initiated
0930:
Epidural inserted by anesthesiology. Client reports pain as 2 on a scale of 0 to 10,
0950:
Spontaneous rupture of membranes with clear fluid
1000:
Variable decelerations noted on the electronic fetal heart rate monitor tracing. FHR baseline 140/min. Deceleration 90/min, lasting 30 seconds. Loop of umbilical cord visible at vaginal introitus.
Vital Signs
0900:
Temperature 36.5°C (97.7°F)
BP 130/84 mm Hg
Heart rate 108/min
Respiratory rate 18/min
Oxygen saturation 98% on room air
0930:
BP 120/78 mm Hg
Heart rate 96/min
Respiratory rate 18/min
Oxygen saturation 98% on room air
1000:
BP 118/84 mm Hg
Heart rate 95/min
Respiratory rate 19/min
Oxygen saturation 97% on room air
Question 4 of 5
Select the 5 actions the nurse should take.
Correct Answer: B, C, D, E, F
Rationale: The correct actions (B, C, D, E, F) are based on managing a prolapsed umbilical cord during labor. B is crucial for timely intervention by involving the provider. C (Trendelenburg position) helps alleviate pressure on the cord. D (upward pressure) helps relieve compression on the cord. E aims to prevent cord compression. F (oxygen) supports fetal oxygenation. A is incorrect as increasing IV flowrate isn't a priority. G is not provided.
Extract:
Question 5 of 5
A nurse is providing an in service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?
Correct Answer: A
Rationale: The correct answer is A because a client who uses a wheelchair and is confused is at the highest risk during a fire evacuation due to mobility limitations and decreased ability to follow instructions. Evacuating this client first ensures their safety and prevents potential delays in the evacuation process.
Choice B is incorrect because a bedridden client wearing a hearing aid can still be safely evacuated with assistance.
Choice C is incorrect as an ambulatory client receiving oxygen can usually move independently and should be evacuated after the client in a wheelchair.
Choice D is incorrect because a client with a fracture in traction can be safely moved with proper equipment and should not be the first priority for evacuation.