ATI RN
ATI RN pharmacology 2023 Questions
Extract:
Nurses' Notes
Diagnostic Results
Vital Signs
0900:
Client is admitted to the unit with a diagnosis of pneumonia. IV of 0.9% sodium chloride infusing into 20-gauge peripheral IV located in the left hand at 90 mL/hr.
1300:
Client has not voided since admission. Bladder is distended and palpable. Provider notified.
1330:
Prescription obtained for intermittent catheterization.
Question 1 of 5
After providing perineal care and donning sterile gloves, the nurse should first ___ followed by ___
| lubricate the catheter tip |
| insert the catheter until urine flows |
Correct Answer: A,B
Rationale:
Rationale:
- The correct sequence is to first lubricate the catheter tip (
A) before inserting it.
- This helps reduce discomfort and trauma to the patient during catheter insertion.
- After lubrication, the nurse should then insert the catheter until urine flows (
B) to ensure proper placement and functionality.
- It is crucial to follow this specific order to maintain aseptic technique and prevent complications like urinary tract infections.
Extract:
Nurses' Notes
Diagnostic Results
Day 1:
The client has left-sided weakness and is unable to ambulate without full assistance. 2+ pedal pulses present and equal bilaterally.
Day 2:
Area of swelling and tenderness noted to back of right calf. Pedal pulses present and equal bilaterally.
Question 2 of 5
The client is at risk for developing ___ due to their ___
| deep vein thrombosis (DVT) |
| immobility |
Correct Answer: A,B
Rationale: [1, 1, 0]
The correct answer is A,B. Deep vein thrombosis is a condition where blood clots form in deep veins, often due to immobility. Immobility can lead to blood pooling and clot formation, increasing the risk of DVT.
Therefore, both choices A and B are correct as they are interlinked in causing DVT.
Choice C and other options are incorrect as they do not directly address the relationship between immobility and the risk of DVT development.
Extract:
Nurses' Notes
Diagnostic Results
0800:
Client 1 is admitted with right hip pain following a fall.
Client 2 has a history of hyperlipidemia.
Client 3 has a history of congestive heart failure.
Client 4 has hypertension and a new prescription for furosemide.
Client 5 has a stage 2 pressure injury on the sacrum.
Client 6 is admitted with a new diagnosis of diabetes mellitus.
Question 3 of 5
The first client the nurse should assess is ___ followed by ___
| Pulmonary edema |
| Glycemic control |
| Hypoalbuminemia |
| Hip fracture |
| Low potassium |
| Malnutrition |
Correct Answer: A,D
Rationale:
The correct answer is A,D. The rationale is to prioritize immediate life-threatening conditions. Pulmonary edema (
A) requires urgent assessment due to potential respiratory compromise. Hip fracture (
D) should be assessed next to prevent further injury. Other choices are not as urgent. Glycemic control (
B) and low potassium (E) are important but not immediate. Hypoalbuminemia (
C), malnutrition (F) can be assessed later unless there are specific concerns.
Extract:
Medication Administration Record
Nurses' Notes
Vital Signs
0830:
Morphine 10 mg subcutaneous every 3 hr PRN pain
Question 4 of 5
Click to highlight the documentation in the client's medical record that requires further action by the nurse.
| Temperature 37.5° C (99.5° F) |
| Client is difficult to arouse. |
| Respiratory rate 10/min |
| Pulse oximetry 88% on room air (95% to 100%) |
| Pupils are 3 mm, equal, and reactive to light. |
| Blood pressure 99/46 mm Hg |
| Heart rate 61/min |
Correct Answer: B,C,D
Rationale:
To select the correct answer, , we must identify concerning signs that require immediate action.
B: A client being difficult to arouse indicates altered consciousness, necessitating urgent attention.
C: A respiratory rate of 10/min is abnormally low and indicates respiratory distress.
D: A pulse oximetry of 88% on room air is below the normal range, indicating hypoxemia.
Incorrect options:
A: Temperature of 37.5°C is within normal range.
E: Pupils being equal and reactive are normal findings.
F: Blood pressure of 99/46 mm Hg is slightly low but not critically concerning.
G: Heart rate of 61/min is within normal limits.
Extract:
Nurses' Notes
Vital Signs
1000:
An older adult client admitted following a fall down approximately five steps. Client's partner reports client possibly hit their head and was a little disoriented for a minute or two. Client states, "I feel fine. I just slipped." Client has a history of falls and orthostatic hypotension per client's partner. Client uses a walker and wears rubber-soled slippers at home. Client ordered new glasses following an eye exam last week but has not received them yet. Partner states they both do exercises that focus on coordination, three times per week.
1400:
An assistive personnel found the client lying on the floor after coming back from the bathroom. Client states, "I'm so sorry. I had to get up to go to the bathroom, and I couldn't wait for someone to help me." Client is awake, alert, and oriented to person, place, and time. Client reports.no pain. Assessment reveals no injury. Client was provided call button and reminded to call for help when getting out of bed Bed alarm activated.
Question 5 of 5
Click to highlight the pieces of information that indicate the client is at risk for falls.
| admitted following a fall down approximately five steps |
| client possibly hit their head and was a little disoriented for a minute or two |
| history of falls and orthostatic hypotension per client's partner |
| uses a walker |
| Client ordered new glasses following an eye exam last week but has not received them yet |
| Lying: 130/90 mm Hg |
| Standing: 98/60 mm Hg |
Correct Answer: A,B,C,D,E,F,G
Rationale:
To determine if a client is at risk for falls, we need to assess various factors that indicate an increased likelihood of falling.
A: Admitted following a fall down approximately five steps - Indicates a recent fall.
B: Client possibly hit their head and was a little disoriented for a minute or two - Suggests potential head injury and disorientation.
C: History of falls and orthostatic hypotension per client's partner - Previous falls and low blood pressure upon standing increase fall risk.
D: Uses a walker - Indicates mobility issues.
E: Client ordered new glasses but has not received them yet - Vision impairment can contribute to falls.
F: Lying: 130/90 mm Hg - High blood pressure can lead to dizziness and falls.
G: Standing: 98/60 mm Hg - Low blood pressure when standing is a risk factor for falls.
Selecting all options A to G provides a comprehensive assessment of fall risk factors for the client.