ATI RN
RN ATI Comprehensive Assessment Exam Retake 2023 V2 Questions
Extract:
Question 1 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 2 of 5
A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to access the port?
Correct Answer: A
Rationale: The correct answer is A: A noncoring needle. A noncoring needle is specifically designed for accessing implanted venous access ports as it prevents coring of the septum, ensuring proper access without causing damage. An angiocatheter is typically used for peripheral IV access, not for accessing ports. A butterfly needle is not suitable for accessing ports as it may cause damage to the septum. A 25 gauge needle is too small and may not provide adequate access to the port.
Therefore, the most appropriate choice for accessing an implanted venous access port is a noncoring needle.
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 3 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 4 of 5
A charge nurse is teaching a newly licensed nurse about medication administration. Which of the following information should the charge nurse include?
Correct Answer: C
Rationale: The correct answer is C: Inform clients about the action of each medication prior to administration. This is essential to ensure informed consent, promote patient autonomy, and enhance medication adherence. Educating clients about their medications allows them to understand why they are taking them and what to expect. This fosters a collaborative patient-provider relationship and empowers clients to actively participate in their care.
Choices A, B, and D are important aspects of medication administration but do not directly involve educating clients about the medication's actions. Avoiding preparing medications for more than two clients at a time (
A) is important for accuracy and safety, completing an incident report for vomiting after medication (
B) is crucial for documentation and follow-up, and reading medication labels twice before administration (
D) is necessary for verification and error prevention. However, these choices do not address the educational aspect of informing clients about their medications.
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 5 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.