RN ATI Comprehensive Assessment Exam Retake 2023 V2 -Nurselytic

Questions 58

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RN ATI Comprehensive Assessment Exam Retake 2023 V2 Questions

Extract:


Question 1 of 5

A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching?

Correct Answer: B

Rationale: The correct answer is B: "I can visit my nephew who has chickenpox 5 days after the sores have crusted." This statement shows understanding of infection prevention because chickenpox is contagious until the sores crust over, typically about 5-7 days after they appear. Visiting the nephew after this period reduces the risk of contracting the virus.

A: Incorrect. Antibiotics are for bacterial infections, not viruses.
C: Incorrect. Pregnant women should avoid cleaning cat litter due to the risk of toxoplasmosis.
D: Incorrect. Handwashing should last at least 20 seconds with soap and water for proper infection prevention.

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.



Day 1, 0930:

Client reports a constant and throbbing headache and rates it as a 6 on a scale of 0 to 10. Denies visual disturbances. +3 pitting edema in bilateral lower extremities. Patellar reflex 4+ without the presence of clonus. Client reports occasional nighttime leg cramps. Reports three fetal movements within the last 30 min. External fetal monitor applied with a baseline FHR 140/min with occasional accelerations and moderate variability. No uterine contractions noted



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

Day 1, 0930:

Temperature (oral) 37.1°C (98.8°F)

Heart rate 84/min

Respiratory rate 18/min

BP 166/110 mm Hg

Oxygen saturation 99% 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)

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 2 of 5

Drag words from the choices below to fill in each blank in the following sentence. The client is at greatest risk for developing-----and-----

Correct Answer: C,E

Rationale: The correct answer is C (Heart failure) and E (Seizures). Heart failure and seizures are commonly associated with severe preeclampsia, a serious pregnancy complication characterized by high blood pressure and organ damage. In severe cases, preeclampsia can lead to heart failure due to the increased strain on the heart and seizures due to cerebral edema. Placental abruption (
A), hypoglycemia (
B), and cervical insufficiency (
D) are not directly related to the client's risk in this scenario. Placental abruption is associated with vaginal bleeding, hypoglycemia with low blood sugar levels, and cervical insufficiency with premature dilation of the cervix.

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 empathy and encourages the client to express their feelings, fostering open communication. By understanding the client's concerns, the nurse can address them effectively, promoting a sense of control and dignity for the client.

Option B is incorrect as it disregards the client's request to not use the bed pan. Option C is incorrect as it assumes the client can be ambulated to the bathroom, which may not be feasible. Option D is incorrect as it is authoritarian and dismisses the client's autonomy. It is essential to prioritize the client's comfort and emotional well-being in end-of-life care.

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 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.

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