ATI RN
RN ATI Comprehensive Assessment Exam Retake 2023 V2 Questions
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 1 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 2 of 5
A nurse is discussing discharge plans with an older adult client who lives alone and has left-sided weakness following a stroke. Which of the following information is the priority for the nurse to discuss?
Correct Answer: B
Rationale: The correct answer is B: Obtaining an alert system to get help in case of a fall. This is the priority because the client has left-sided weakness following a stroke, making them at higher risk for falls and potential injuries. Having an alert system in place ensures quick assistance in case of a fall, potentially preventing serious consequences. Reviewing support groups (
A) is important for emotional support but not as urgent as fall prevention. Providing transportation resources (
C) can be discussed later once safety concerns are addressed. Choosing an agency for physical therapy (
D) is important but secondary to immediate safety needs.
Question 3 of 5
A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make?
Correct Answer: D
Rationale: The correct answer is D: "I can give you information about respite care if you are interested." This response shows empathy and offers a practical solution to address the son's sleep deprivation. Respite care can provide temporary relief for caregivers, allowing them to rest and recharge. This option acknowledges the son's challenges and offers support without assuming he needs medication or providing generic comments. Option A is not ideal as it jumps to prescribing medication without exploring other options. Option B is a general statement that doesn't address the son's specific situation. Option C, while positive, does not offer a solution to his sleep deprivation.
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.
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
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)
Question 4 of 5
The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.
Correct Answer: A, B, C, F
Rationale:
Correct Answer: A, B, C, F
Rationale:
A: Urine protein indicates possible preeclampsia, a serious prenatal complication.
B: Decreased fetal activity can signal fetal distress or other issues.
C: Abnormal blood pressure levels may indicate gestational hypertension or preeclampsia.
F: Headaches can be a symptom of preeclampsia, requiring immediate attention to prevent complications.
Incorrect
Choices:
D: Urine ketones usually indicate dehydration or inadequate nutrition, not a prenatal complication.
E: Respiratory rate is not typically used to assess prenatal complications.
G: Gravida/parity information is important but does not directly indicate a prenatal complication.
Extract:
Question 5 of 5
A nurse is providing discharge instructions to a client who has a new prescription for haloperidol. Which of the following adverse effects should the nurse instruct the client to report to the provider?
Correct Answer: C
Rationale: The correct answer is C: Shuffling gait. Haloperidol is an antipsychotic medication that can cause extrapyramidal symptoms like shuffling gait, which is a serious adverse effect requiring immediate medical attention to prevent further complications. A: Weight gain is a common side effect but not urgent. B: Dry mouth is a common side effect that can be managed with oral hygiene. D: Sedation is a common side effect that may resolve over time.