ATI RN
RN ATI Comprehensive Assessment Exam Retake 2023 V2 Questions
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 1 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 and D. Lithium toxicity and nephrotoxicity are commonly associated with the use of lithium. The nurse needs to monitor the patient for signs and symptoms of lithium toxicity, such as tremors, confusion, and increased thirst, as well as signs of nephrotoxicity, like decreased urine output and electrolyte imbalances. Hyponatremia (
B), cardiac dysrhythmias (
C), metabolic alkalosis (E), and hypertension (F) are not directly related to lithium use. Monitoring for these conditions would not be the priority in a patient who has likely developed lithium toxicity and nephrotoxicity.
Extract:
Question 2 of 5
A nurse is preparing to initiate intravenous fluids via infusion pump for a client. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Check the expiration date on the safety inspection sticker of the pump. This is crucial for ensuring the safety and efficacy of the pump. Checking the expiration date ensures that the pump has been recently inspected and is functioning properly, reducing the risk of malfunctions.
A: Obtaining a surge protector is important for electrical safety, but it is not directly related to the specific task of initiating intravenous fluids via an infusion pump.
B: Verifying that the extension cord is ungrounded is unsafe as it increases the risk of electrical hazards.
C: Reporting a frayed cord is essential for patient safety, but proceeding with the infusion without addressing the issue is dangerous.
E, F, G: No information provided.
Question 3 of 5
A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to access the port?
Correct Answer: A
Rationale: The correct answer is A: A noncoring needle. This type of needle is specifically designed for accessing implanted venous access ports as it minimizes damage to the port septum, reducing the risk of infection and catheter damage. The noncoring needle has a special tip that creates a clean puncture without coring (cutting) the septum, ensuring proper access without compromising the integrity of the port.
Summary of why the other choices are incorrect:
B: An angiocatheter is not recommended for accessing venous access ports as it is not designed for this purpose and can cause damage to the port.
C: A butterfly needle is not suitable for accessing venous access ports as it can cause coring of the septum and increase the risk of infection.
D: A 25 gauge needle is too small and not suitable for accessing implanted venous access ports as it may not provide adequate flow rates and can lead to difficulty in accessing the port.
Question 4 of 5
A nurse is conducting an initial assessment of a client and notices a discrepancy between the client's current IV infusion and the information received during the shift report. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Compare the current infusion with the prescription in the client's medication record. This is the best course of action as it allows the nurse to verify the accuracy of the IV infusion against the prescribed treatment plan. By cross-referencing the current infusion with the prescription in the client's medication record, the nurse can identify any discrepancies and take appropriate actions to ensure the client's safety and well-being.
Choice A is incorrect because contacting the charge nurse may not provide the necessary information to verify the accuracy of the IV infusion.
Choice B is incorrect as completing an incident report is premature without first verifying the discrepancy.
Choice C is inappropriate and punitive without a proper investigation.
Choices E, F, and G are not provided in the question, so they are irrelevant.
Extract:
Nurses: Notes
0700
Client is admitted to the unit. They deny suicidal ideations at this time. Client states, 'I am an assistant to a powerful spirit.' Client is poorly groomed and has body odor.
0900:
Called to the client's room. Client states, 'I cannot believe you put me in a room with spiders on the wall,' Client requests immediate transfer to another room.
1200:
Psychiatrist is at the bedside evaluating the client. After history and physical, psychiatrist states that they have diagnosed the client with schizophrenia. Client is to be started on medication and milieu therapy.
Laboratory Results
0700:
Urine drug screen: negative (negative)
History and Physical
0700:
Majority of client's history is obtained from client's parent who presents with client today. According to the parent, client has been acting strangely for a few months. Client's symptoms have been progressively worsening
In the last month, the client has been seeing things that are not present and believes that they are in a close relationship with 'a powerful spirit.' Client has not been bathing regularly for the last few weeks.
Client has no significant health history. Client reports that they do not take illicit substances or drink alcohol. Client's grandparent has a history of schizophrenia.
Vital Signs
0730:
Heart rate 68/min
Respiratory rate 18/min
BP 118/81 mm Hg
Temperature 37.2°C (98.9°F)
Question 5 of 5
For each potential action, click to specify if the action is indicated or contraindicated for the client.
Correct Answer: B, C, D indicated; A, E contraindicated
Rationale:
Correct
Answer: B, C, D indicated; A, E contraindicated
Rationale:
1. B is indicated because asking about hallucinations can help assess the client's mental state.
2. C is indicated as maintaining hygiene is important for the client's well-being.
3. D is indicated to assess and address any suicidal ideation for client safety.
4. A is contraindicated as high TV volume can worsen auditory hallucinations.
5. E is contraindicated as placing near activity room may cause overstimulation and distress.