ATI RN
RN ATI Comprehensive Assessment Exam Retake 2023 V2 Questions
Extract:
Question 1 of 5
A nurse is teaching a client about family planning using the basal body temperature method. Which of the following instructions should the nurse include in the teaching?
Correct Answer: A
Rationale: The correct answer is A: "Take your temperature immediately after waking and before getting out of bed." This instruction is crucial for accurately tracking basal body temperature, as it helps minimize external factors that could affect the reading. Taking the temperature before getting out of bed ensures consistency in the readings, as any physical activity or movement can influence the results. By measuring the temperature at the same time each morning, variations can be detected, which is essential for determining ovulation and fertile periods.
Choice B is incorrect as waiting 30 minutes after waking can introduce inaccuracies due to possible activities during that time.
Choice C is incorrect because taking the temperature an hour after waking can lead to fluctuations in readings.
Choice D is incorrect as taking the temperature before going to bed does not capture the basal body temperature accurately.
Question 2 of 5
A nurse is planning care for a client who has acute appendicitis. Which of the following actions should the nurse plan to take?
Correct Answer: C
Rationale:
Correct Answer: C - Keep the client on NPO status
Rationale: In acute appendicitis, the client may require urgent surgery to remove the inflamed appendix. Keeping the client NPO (nothing by mouth) is essential to avoid potential complications during surgery, such as aspiration of stomach contents. This action also helps prevent delays in the surgical intervention and minimizes the risk of infection.
Incorrect
Choices:
A: Placing the client's head of bed flat can increase intra-abdominal pressure and worsen the client's condition.
B: Applying heat to the client's abdomen can exacerbate inflammation and may mask the symptoms, delaying appropriate treatment.
D: Administering a laxative can be dangerous as it may cause the appendix to rupture due to increased pressure from fecal matter.
Question 3 of 5
A nurse is caring for a client whose child died from cancer. The client states, 'It's hard to go on without him.' Which of the following questions should the nurse ask the client first?
Correct Answer: D
Rationale: The correct answer is D: "Are you thinking about ending your life?" This question is crucial as it directly addresses the client's statement about finding it hard to go on without their child, indicating potential suicidal ideation. By asking this question first, the nurse can assess the client's risk of harm and provide appropriate interventions if necessary.
Option A: "What has helped you through difficult times in the past?" - While this is a supportive question, it does not address the immediate concern of suicidal ideation.
Option B: "Has anyone in your family committed suicide?" - This question may be relevant but is not as urgent as directly asking about the client's current thoughts of ending their own life.
Option C: "Is there anyone you would like involved in your care?" - This question focuses more on the client's support system rather than addressing the potential risk of harm.
In summary, asking about suicidal thoughts first is crucial in ensuring the client's safety and well-being in this scenario.
Extract:
Graphic Record
Admission weight 74.8 kg (165 lb)
Current weight 74.38 kg (164 lb)
Provider Prescriptions
Lisinopril 10 mg daily
Lithium 600 mg BID
Omeprazole 40 mg daily
I&O
Prior Day Intake and Output
0800:
Intake 30 mL orange juice
Output 800 mL clear urine
1200:
Intake 60 ml water with lunch
Output 300 ml clear urine
1800
Intake 120 ml. water with dinner
Output 500 mL clear urine
2100:
Intake 30 ml dark soda
Output 200 ml. clear urine
Nurses Notes
0800:
A client who has bipolar disorder is admitted to the inpatient psychiatric unit. During the morning assessment, the client reports blurred vision and an increase in urine output. It is noted that the client is having clonic jerking of upper extremities. Provider notified and laboratory tests ordered. Skin is warm and dry without rash.
Laboratory Results
0900:
Creatinine 0.9 mg/dL (0.5 to 1.1 mg/dL)
Lithium level 2.5 mEq/L (0.6 to 1.2 mEq/L)
Fasting blood glucose 80 mg/dL (74 to 106 mg/dL)
Urinalysis:
Appearance: clear (clear)
Color: faint yellow (amber yellow)
Specific gravity 1.32 (adult client 1.01 to 1.025)
Nitrites: none (none)
Ketones: none (none)
Bilirubin: none (none)
Question 4 of 5
Complete the following sentence by using the lists of options. The nurse understands that the patient has likely developed-----and will need to be monitored for-------
Correct Answer: A,D
Rationale: The correct answer is A (Lithium toxicity) and D (nephrotoxicity). The nurse is likely considering lithium toxicity due to the patient's potential symptoms and the need for monitoring kidney function. Lithium toxicity can lead to nephrotoxicity, affecting kidney function. The other options are less likely based on the given information. Hyponatremia is a potential side effect of lithium, but not the primary concern here. Cardiac dysrhythmias, metabolic alkalosis, and hypertension are not typically associated with lithium toxicity.
Therefore, A and D are the most appropriate choices for the nurse to consider and monitor.
Extract:
Question 5 of 5
A nurse is caring for a client who is postoperative following a liver biopsy. In which of the following positions should the nurse place the client immediately following the procedure?
Correct Answer: D
Rationale: The correct answer is D: Right lateral. Placing the client in the right lateral position immediately after a liver biopsy helps to apply pressure to the biopsy site, minimizing the risk of bleeding. This position also facilitates drainage of any blood or fluid that may accumulate at the biopsy site.
A: Prone position is not ideal for a client post-liver biopsy as it may put pressure on the biopsy site, increasing the risk of bleeding.
B: Trendelenburg position, with the client's feet elevated above the head, is not necessary and may not provide the desired pressure on the biopsy site.
C: High-Fowler's position, with the client sitting upright, does not offer the same benefits as the right lateral position in terms of pressure and drainage at the biopsy site.
In summary, the right lateral position is the most appropriate choice post-liver biopsy to promote hemostasis and prevent complications.