ATI RN
RN ATI Comprehensive Assessment Exam Retake 2023 V2 Questions
Extract:
Question 1 of 5
A nurse is providing discharge instructions to a client who has a new prescription for haloperidol. Which of the following adverse effects should the nurse instruct the client to report to the provider?
Correct Answer: C
Rationale: The correct answer is C: Shuffling gait. Haloperidol is an antipsychotic medication that can cause extrapyramidal symptoms like shuffling gait, which is a serious adverse effect requiring immediate medical attention to prevent further complications. A: Weight gain is a common side effect but not urgent. B: Dry mouth is a common side effect that can be managed with oral hygiene. D: Sedation is a common side effect that may resolve over time.
Extract:
Nurses Notes
Today
0800:
Client reports not feeling well with headache, body aches, and chills. Left breast red and tender with swollen, tender lymph nodes in the left axilla. Incision edges well approximated without erythema or drainage. Small amount of lochia rubra noted.
0830
Provider notified of findings. Prescriptions received
Question 2 of 5
For each potential assessment finding, click to specify if the assessment finding is consistent with mastitis or endometritis. Each finding may support more than 1 disease process.
Correct Answer: B: Mastitis; A, C, D: Both
Rationale: The correct answer is B: Painful, tender breast for mastitis. Mastitis is an infection of the breast tissue, causing pain and tenderness. Foul-smelling lochia can be consistent with both mastitis and endometritis, as it indicates infection. Temperature and chills are non-specific findings that can be present in both mastitis and endometritis. In summary, the painful, tender breast is a specific finding for mastitis, while foul-smelling lochia, temperature, and chills can be seen in both conditions due to the presence of infection.
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 3 of 5
Select the 5 actions the nurse should take.
Correct Answer: B, C, D, E, F
Rationale: The correct actions are B, C, D, E, and F. B is crucial for timely provider notification. C helps improve placental perfusion. D can alleviate cord compression. E can prevent cord prolapse complications. F ensures adequate oxygenation. A is incorrect as it doesn't address the immediate issue. G is omitted.
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.
Question 5 of 5
A nurse is teaching a newly licensed nurse about caring for clients in the emergency department. Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?
Correct Answer: C
Rationale: The correct answer is C: Tell the client, 'You seem to be very upset.' This response demonstrates empathy and acknowledgment of the client's emotional state, which can help de-escalate the situation. By acknowledging the client's feelings, the nurse shows understanding and may help the client feel heard and understood. This can also open the door for further communication to address the client's concerns.
Incorrect answers:
A: Initiating seclusion protocol is not appropriate in this situation as it may escalate the client's agitation.
B: Using a face shield with a mask does not address the client's emotional state and may further alienate the client.
D: Engaging the panic alarm is an extreme response and should only be used in cases of imminent danger, which is not indicated here.