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
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)
BUN 19 mg/dL (10 to 20 mg/dL)
Creatinine 0.8 mg/dL (0.5 to 1 mg/dL)
WBC 8,000/mm³ (5,000 to 10,000/mm³)
Glucose 85 mg/dL (74 to 106 mg/dL)
Liver Enzymes:
Alanine aminotransferase (ALT) 40 units/L (4 to 36 units/L)
Aspartate aminotransferase (AST) 42 units/L (0 to 35 units/L)
Total bilirubin 1.2 mg/dL (0.3 to 1 mg/dL)
Question 1 of 5
The nurse is reviewing the assessment findings. For each assessment finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process
Correct Answer: C: Preeclampsia; A, B, D: HELLP
Rationale:
Correct Answer: C: Preeclampsia; A, B, D: HELLP
Rationale:
1. Blood pressure: Elevated blood pressure is a hallmark sign of preeclampsia due to vasoconstriction.
2. Hemoglobin (
A): Low hemoglobin levels are indicative of HELLP syndrome, a severe form of preeclampsia.
3. Alanine aminotransferase (ALT) (
B): Elevated ALT levels are associated with liver dysfunction in HELLP syndrome.
4. Platelet count (
D): Low platelet count is a characteristic finding in HELLP syndrome due to platelet aggregation.
Summary:
- Hemoglobin, ALT, and platelet count are specific to HELLP syndrome, not preeclampsia.
- Blood pressure is a key feature of preeclampsia, distinguishing it from HELLP syndrome.
Extract:
Question 2 of 5
A nurse is caring for a client whose child died from cancer. The client states, 'It's hard to go on without him.' Which of the following questions should the nurse ask the client first?
Correct Answer: D
Rationale: The correct answer is D: "Are you thinking about ending your life?" This question is crucial as it directly addresses the client's statement about finding it hard to go on without their child, indicating potential suicidal ideation. By asking this question first, the nurse can assess the client's risk of harm and provide appropriate interventions if necessary.
Option A: "What has helped you through difficult times in the past?" - While this is a supportive question, it does not address the immediate concern of suicidal ideation.
Option B: "Has anyone in your family committed suicide?" - This question may be relevant but is not as urgent as directly asking about the client's current thoughts of ending their own life.
Option C: "Is there anyone you would like involved in your care?" - This question focuses more on the client's support system rather than addressing the potential risk of harm.
In summary, asking about suicidal thoughts first is crucial in ensuring the client's safety and well-being in this scenario.
Question 3 of 5
A nurse is performing a neurological examination on a client as part of a complete physical assessment. The nurse should identify that cranial nerve XI is intact when the client performs which of the following actions?
Correct Answer: A
Rationale: The correct answer is A: Shrugs his shoulders. Cranial nerve XI, also known as the spinal accessory nerve, innervates the trapezius and sternocleidomastoid muscles responsible for shoulder shrugging. By asking the client to shrug his shoulders against resistance, the nurse can assess the integrity of cranial nerve XI. Sticking the tongue out (choice
B) involves cranial nerve XII, frowning symmetrically (choice
C) involves cranial nerve VII, and identifying a sour taste (choice
D) involves cranial nerve IX and VII. These actions do not assess cranial nerve XI.
Question 4 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. A noncoring needle is specifically designed for accessing implanted venous access ports as it prevents coring of the septum, ensuring proper access without causing damage. An angiocatheter is typically used for peripheral IV access, not for accessing ports. A butterfly needle is not suitable for accessing ports as it may cause damage to the septum. A 25 gauge needle is too small and may not provide adequate access to the port.
Therefore, the most appropriate choice for accessing an implanted venous access port is a noncoring needle.
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 5 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.