ATI RN
RN ATI Comprehensive Assessment Exam Retake 2023 V2 Questions
Extract:
Nurses' Notes
0900:
Contractions occurring every 3 to 4 min, lasting 80 to 90 seconds. Client rates pain with contractions as 10 on a scale of 0 to 10 and requests an epidural. Contractions approximately 4 min apart. Vaginal examination reveals cervix dilated 5 cm, 80% effaced, -1 station, vertex presentation. FHR baseline 142/min with moderate variability, IV fluid bolus initiated
0930:
Epidural inserted by anesthesiology. Client reports pain as 2 on a scale of 0 to 10,
0950:
Spontaneous rupture of membranes with clear fluid
1000:
Variable decelerations noted on the electronic fetal heart rate monitor tracing. FHR baseline 140/min. Deceleration 90/min, lasting 30 seconds. Loop of umbilical cord visible at vaginal introitus.
Vital Signs
0900:
Temperature 36.5°C (97.7°F)
BP 130/84 mm Hg
Heart rate 108/min
Respiratory rate 18/min
Oxygen saturation 98% on room air
0930:
BP 120/78 mm Hg
Heart rate 96/min
Respiratory rate 18/min
Oxygen saturation 98% on room air
1000:
BP 118/84 mm Hg
Heart rate 95/min
Respiratory rate 19/min
Oxygen saturation 97% on room air
Question 1 of 5
Select the 5 actions the nurse should take.
Correct Answer: B, C, D, E, F
Rationale: The correct actions are B, C, D, E, and F. B is crucial for timely provider notification. C helps improve placental perfusion. D can alleviate cord compression. E can prevent cord prolapse complications. F ensures adequate oxygenation. A is incorrect as it doesn't address the immediate issue. G is omitted.
Extract:
History and Physical
Day 1, 0900:
A 52-year-old client brought to the emergency department by an adult child. The client is alert and oriented to person and time but does not know where they are. No history of substance use according to the client's adult child. The client exhibits constant movements and poor concentration. Hair and clothing are unclean. Appears to be listening to unseen others. Skin turgor poor.
Vital Signs
Day 1, 0905:
Temperature 37.1°C (98.8°F)
Heart rate 120/min
Respiratory rate 19/min
BP 138/88 mm Hg
Oxygen saturation 98% on room air
Question 2 of 5
The nurse is assessing the client. Select the 4 findings that require immediate follow-up
Correct Answer: A, B, D, E
Rationale: The correct answer is A, B, D, and E. Hallucinations require immediate follow-up as they may indicate a serious underlying condition. Heart rate abnormalities could signify cardiac issues needing urgent attention. Skin turgor changes suggest dehydration, requiring immediate intervention. Poor hygiene can lead to infections, necessitating prompt follow-up. Sleep pattern changes and assessing vital signs (such as heart rate) are crucial aspects of client assessment.
Choices C and F are not as urgent, as sleep pattern changes may not require immediate action, and choice F is incomplete.
Extract:
Question 3 of 5
A nurse is preparing to admit a 6-year-old with varicella to the pediatric unit. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Assign the child to a negative air pressure room. Varicella, commonly known as chickenpox, is highly contagious via airborne droplets. Placing the child in a negative air pressure room helps prevent the spread of the virus to other patients and healthcare workers. This isolation precaution is crucial in controlling the transmission of varicella. Administering aspirin (choice
B) is contraindicated in varicella due to the risk of Reye's syndrome. Using droplet precautions (choice
C) is not appropriate for varicella, as it is transmitted through airborne particles. Assessing for Koplik spots (choice
D) is related to measles, not varicella.
Question 4 of 5
A nurse is caring for a client who is receiving brachytherapy for endometrial cancer. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Keep visitors at least 6 feet (1.8 m) away from the client. This is crucial in brachytherapy as the client is radioactive. Keeping visitors at a safe distance minimizes their exposure to radiation. Discarding the radioactive source in the client's trash can (
A) is hazardous. Placing soiled bed linens in a biohazard bag (
B) is necessary but not specific to radiation precautions. Wearing an isolation gown (
C) does not provide sufficient protection from radiation.
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: 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.