ATI RN
ATI RN pharmacology 2023 Questions
Extract:
Medication Administration Record
Nurses' Notes
Vital Signs
0830:
Morphine 10 mg subcutaneous every 3 hr PRN pain
Question 1 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 2 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.
Extract:
Nurses' Notes
Vital Signs
Laboratory Results
0950:
A male client transferred to room from PACU following abdominal surgery. Report received that estimated blood loss in the procedure was 1200 mL. Client is alert and talking. Lung sounds clear, heart regular rate and rhythm, hypoactive bowel sounds. Sequential compression devices in place and peripheral pulses palpable and equal bilaterally. Client can feel and wiggle toes.
1025:
Called to room. Client appears agitated. The client states, "I feel like something is wrong." Lung sounds clear, increased rate and depth of respirations noted. Client rates incisional pain as 5 on a scale of 0 to 10. Surgical dressing dry and intact. Hypoactive bowel sounds. Peripheral pulses palpable and strong capillary refill time (CRT) less than 3 seconds,
Question 3 of 5
The nurse should first follow up on the client's ___ and ___
| oxygen saturation |
| pain |
| WBC count |
| behavioral findings |
| bowel findings |
Correct Answer: A,D
Rationale:
Step-by-step rationale for selecting A and D as the correct answers:
1. Oxygen saturation : This is crucial to assess the client's respiratory status and ensure adequate oxygenation, which is a priority in any healthcare setting.
2. Behavioral findings (
D): Changes in behavior can indicate pain, distress, or other underlying issues that may require immediate attention.
3. Pain (
B): While pain is important to assess, oxygen saturation and behavioral findings (
D) take precedence as they are more directly related to the client's immediate well-being.
4. WBC count (
C): While WBC count can indicate infection, it is not typically the first assessment to be done unless there are specific signs or symptoms suggesting an infection.
5. Bowel findings (E): While bowel findings are important, they are not typically the first assessments to be done unless the client is presenting with specific gastrointestinal complaints.
Therefore, the correct answers are A and D because they are the most critical assessments
Extract:
Medical History
Medication Administration Record
Diagnostic Results
Day 1:
0800:
The client is postoperative following a hip arthroplasty.
Question 4 of 5
The client is at risk for developing ___ due to ___
| Confusion |
| Pressure injuries |
| Hypoglycemia |
| Constipation |
| Dysrhythmias |
| Opioid use |
| Immobility |
Correct Answer: A,D
Rationale: [0, 0, 1, 1, 0, 0, 1]
To determine the correct answer, consider the client's risk factors. Confusion can result from constipation (
D) due to the impact of bowel issues on cognition.
Therefore, the correct choices are A and D. Pressure injuries (
B) are more related to immobility (G), hypoglycemia (
C) is linked to medication or dietary factors, dysrhythmias (E) are often cardiac-related, and opioid use (F) may lead to constipation but not confusion in this context.
Extract:
Vital Signs
Medical History
Nurses' Notes
1000:
Temperature 36° C (96.8° F)
Blood pressure 118/56 mm Hg
Heart rate 92/min
Respiratory rate 18/min
Oxygen saturation 95% on room air
1200:
Temperature 37.2° C (99° F)
Blood pressure 104/56 mm Hg
Heart rate 62/min
Respiratory rate 12/min
Oxygen saturation 94% on room air
Question 5 of 5
The client is most at risk of developing ___ and ___
| urinary tract infection |
| delayed wound healing |
| deep vein thrombosis |
| atelectasis |
| paralytic ileus |
Correct Answer: D,E
Rationale: Parameters:
Correct
Answer: (0, 0, 0, 1, 1, 0, 0)
Rationale:
- Atelectasis is a condition where the lungs do not expand fully, increasing the risk of respiratory complications.
- Paralytic ileus is a condition where the intestines stop working, leading to potential bowel obstruction.
- Urinary tract infection, delayed wound healing, and deep vein thrombosis are not directly related to the client's risk factors in this scenario.