ATI RN
RN ATI Comprehensive Assessment Exam Retake 2023 V2 Questions
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 1 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:
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 2 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.
Extract:
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 3 of 5
The nurse is initiating the client's plan of care. Which of the following interventions should the nurse plan to implement? Select all that apply
Correct Answer: A, B, C, D, E, F
Rationale: The correct interventions for the nurse to implement are A, B, C, D, E, and F. A low-stimulation environment helps promote healing and reduce stress. Bed rest may be necessary for certain conditions. Antihypertensive medication is crucial for managing high blood pressure. Betamethasone may be prescribed for various conditions. Monitoring intake and output is essential for assessing fluid balance. Obtaining a 24-hr urine specimen helps evaluate kidney function.
Choices G is incorrect as performing vaginal examinations every 12 hours is not a routine nursing intervention and may be invasive and unnecessary in many cases.
Extract:
Question 4 of 5
A nurse is assessing a client who is postoperative and has a history of pulmonary embolism. Which of the following findings is the priority for the nurse to report to the provider?
Correct Answer: C
Rationale: The correct answer is C: Dyspnea. Dyspnea in a postoperative client with a history of pulmonary embolism is a critical finding indicating potential respiratory distress. This could be a sign of a recurrent pulmonary embolism or worsening respiratory status, requiring immediate intervention. Tachycardia (
A) can be a normal response postoperatively. Dry cough (
B) may be indicative of irritation but is not as urgent as dyspnea. Hypotension (
D) is concerning but not as immediately life-threatening as respiratory distress.
Question 5 of 5
A nurse is inserting an indwelling urinary catheter for a male client. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Lift the penis so that it is perpendicular to the client's body. By lifting the penis perpendicular to the client's body during catheter insertion, the nurse straightens the urethra, making the insertion easier and reducing the risk of injury. This position also helps in maintaining proper alignment for successful catheterization.
A: Performing the cleansing procedure with a fresh swab two times is not directly related to the correct technique of lifting the penis perpendicular to the body.
B: Picking up the catheter 13 cm from its tip is not a necessary step for proper catheter insertion.
C: Cleansing the tip of the penis in a side-to-side motion is not as crucial as lifting the penis for successful catheterization.
In summary, the other choices are incorrect as they do not address the crucial step of lifting the penis perpendicular to the client's body during catheter insertion.