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.
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 1 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: The correct answer includes findings that are indicative of potential prenatal complications.
A: Urine protein can indicate preeclampsia, a serious condition in pregnancy.
B: Fetal activity changes may suggest fetal distress or growth restriction.
C: Blood pressure changes can indicate hypertension or preeclampsia.
F: Headache can be a symptom of preeclampsia or other serious conditions.
Choices D, E, and G are not typically associated with prenatal complications. D: Urine ketones may indicate dehydration but not necessarily a prenatal complication. E: Respiratory rate is not directly related to prenatal complications. G: Gravida/parity information is important for obstetric history but not directly indicative of current prenatal complications.
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 2 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: The correct answer is: C: Preeclampsia; A, B, D: HELLP.
1. Blood pressure is consistent with preeclampsia as elevated blood pressure is a key characteristic.
2. Hemoglobin, Alanine aminotransferase (ALT), and Platelet count are consistent with HELLP syndrome, as these markers are commonly affected in this condition.
3. Preeclampsia is characterized by hypertension and proteinuria, while HELLP syndrome involves hemolysis, elevated liver enzymes, and low platelet count.
4.
Therefore, based on the assessment findings provided, elevated blood pressure aligns with preeclampsia, while abnormalities in hemoglobin, ALT, and platelet count suggest HELLP syndrome.
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 3 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. The client is at greatest risk for developing heart failure and seizures due to complications during pregnancy. Heart failure can occur due to the increased stress on the heart from pregnancy, especially in individuals with pre-existing heart conditions. Seizures can arise from conditions like eclampsia, which is a severe form of preeclampsia characterized by high blood pressure and organ damage. Placental abruption (
A) is a separation of the placenta from the uterus, not directly related to heart failure or seizures. Hypoglycemia (
B) is low blood sugar levels, which may occur but is not the greatest risk in this scenario. Cervical insufficiency (
D) is the inability of the cervix to stay closed during pregnancy, which is not directly linked to heart failure or seizures.
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 4 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:
Correct
Answer: A, B, C, D, E, F
Rationale:
A: Providing a low-stimulation environment promotes rest and reduces stress.
B: Maintaining bed rest may be necessary for certain conditions to prevent complications.
C: Giving antihypertensive medication helps control blood pressure.
D: Administering betamethasone can be part of the treatment plan for certain conditions.
E: Monitoring intake and output hourly helps assess fluid balance and kidney function.
F: Obtaining a 24-hr urine specimen is a common diagnostic test to assess kidney function.
Summary:
Choice G is incorrect as performing vaginal examinations every 12 hours is unnecessary and invasive.
Extract:
Question 5 of 5
A nurse is teaching a client who is trying to conceive. Which of the following should the nurse instruct the client to increase in her diet to prevent a neural tube defect?
Correct Answer: B
Rationale: The correct answer is B: Folate. Folate is essential for preventing neural tube defects in newborns. It helps in the formation of the neural tube during early pregnancy. Calcium (
A) is important for bone health but not specifically for preventing neural tube defects. Iron (
C) is crucial for preventing anemia but not directly related to neural tube defects. Zinc (
D) is important for immune function and wound healing but not specifically for neural tube defects.