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 (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:
Nurses Notes
Today
0800:
Client reports not feeling well with headache, body aches, and chills. Left breast red and tender with swollen, tender lymph nodes in the left axilla. Incision edges well approximated without erythema or drainage. Small amount of lochia rubra noted.
0830
Provider notified of findings. Prescriptions received
Question 2 of 5
For each potential assessment finding, click to specify if the assessment finding is consistent with mastitis or endometritis. Each finding may support more than 1 disease process.
Correct Answer: B: Mastitis; A, C, D: Both
Rationale: The correct answer is B: Painful, tender breast for mastitis. Mastitis is an infection of the breast tissue, causing pain and tenderness. Foul-smelling lochia can be consistent with both mastitis and endometritis, as it indicates infection. Temperature and chills are non-specific findings that can be present in both mastitis and endometritis. In summary, the painful, tender breast is a specific finding for mastitis, while foul-smelling lochia, temperature, and chills can be seen in both conditions due to the presence of infection.
Extract:
Question 3 of 5
A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take?
Correct Answer: C
Rationale: The correct answer is C: Protect the IV bag from exposure to light. Nitroprusside is light-sensitive and exposure to light can cause it to degrade, leading to potential harm to the patient. The nurse should take this action to maintain the integrity of the medication. Monitoring blood pressure every 2 hours (choice
A) is important but not specific to nitroprusside administration. Attaching an inline filter to the IV tubing (choice
B) may be unnecessary for nitroprusside administration. Keeping calcium gluconate at the client's bedside (choice
D) is not directly related to the administration of nitroprusside.
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 4 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: The correct answer is B, C, D indicated; A, E contraindicated.
- B: Asking the client about the content of their hallucinations is indicated as it helps assess their mental state.
- C: Instructing the client on expected hygiene practices is indicated for their overall well-being.
- D: Assessing the client for suicidal ideation is crucial for identifying any potential risk.
- A: Allowing the client to watch TV at a high volume can exacerbate hallucinations, so it is contraindicated.
- E: Placing the client in a room near the activity room may increase sensory stimulation, worsening their condition, so it is contraindicated.
Extract:
Nurses' Notes
1100:
The client reports shortness of breath and difficulty sleeping. The client feels tired very quickly and occasionally feels nauseous. The client reports experiencing intermittent chest tightness and a cough that is aggravated by exercise. The client has a productive cough and irregular breathing pattern. Crackles and wheezing present on auscultation. The client has a history of smoking a pack of cigarettes per day for the past 35 years. There is no clubbing of the fingers. The client appears anxious.
1130:
Administered albuterol and oxygen per provider's prescription.
The client is instructed to perform pursed-lip breathing.
1230:
The client is breathing with minimal effort and coughing has decreased.
Vital Signs
1100:
Temperature 35.8°C (98.2°F)
Heart rate 92/min
Respiratory rate 28/min
BP 145/90 mm Hg
Oxygen saturation 87% on room air
1145:
Temperature 36.2°C (97.2°F)
Heart rate 88/min
Respiratory rate 22/min
BP 140/90 mm Hg
Oxygen saturation 92% on room air
Question 5 of 5
Which of the following interventions should the nurse include in the plan of care? Select all that apply.
Correct Answer: A, B, F
Rationale: The correct interventions are A, B, and F. Increasing oxygen flow rate to 4 L/min helps improve oxygenation. Assessing breath sounds is crucial to monitor respiratory status. Instructing the client to perform diaphragmatic breathing aids in improving lung function. Chest percussion and vibration (
C) are not typically indicated for all respiratory conditions and may not be appropriate in this case. Placing the client in a supine position (
D) may worsen respiratory effort. Restricting fluid intake (E) may lead to dehydration and thicken respiratory secretions.