ATI RN
ATI Comprehensive 2023 With NGN 180 Questions And Answers Questions
Extract:
A nurse is reporting a client's laboratory test to the provider to obtain a prescription for warfarin.
Question 1 of 5
Which laboratory test should the nurse report?
Correct Answer: A
Rationale: The correct answer is A: INR. The nurse should report the INR (International Normalized Ratio) test because it specifically measures the effectiveness of anticoagulant therapy like warfarin. A high INR indicates a higher risk of bleeding, while a low INR indicates a higher risk of clotting. Reporting the INR can help healthcare providers adjust medication dosage to maintain optimal therapeutic levels.
Incorrect choices:
B: Prothrombin time (PT) is related to INR but is less specific for monitoring anticoagulant therapy.
C: Activated partial thromboplastin time (aPTT) is used to monitor heparin therapy, not warfarin.
D: Platelet count assesses the number of platelets, not the effectiveness of anticoagulant therapy.
E: Hemoglobin and hematocrit levels assess blood volume and oxygen-carrying capacity, not anticoagulant therapy.
Extract:
A nurse is preparing a client for transfer to a long-term care rehabilitation facility following a below-the-knee amputation.
Question 2 of 5
Which action should the nurse take to protect the client's confidentiality?
Correct Answer: E
Rationale: The correct answer is E: Use a secure and private communication method to discuss the client's condition with the receiving facility. This is the best action to protect the client's confidentiality because it ensures that sensitive information is shared in a confidential and secure manner, preventing unauthorized access. Verbal reports (choice
A) can be overheard, risking confidentiality. While ensuring medical records are transferred securely (choice
B) is important, discussing the client's condition directly with the necessary healthcare providers (choice
D) is more immediate and can prevent unnecessary exposure of sensitive information. Giving the client a copy of their medical records (choice
C) can compromise confidentiality if misplaced.
Extract:
A nurse is admitting an older adult client who was transferred from another facility.
Question 3 of 5
Which action should the nurse take to address suspicion of elder abuse?
Correct Answer: C
Rationale: The correct action for the nurse to address suspicion of elder abuse is to report the findings to the appropriate authorities, following facility protocol (
Choice
C). This is because reporting to the authorities is crucial to protect the elderly individual from further harm and ensure that the necessary interventions are implemented.
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Choice A: Privately interviewing the client may jeopardize the safety of the elderly individual and may not be the most effective immediate action.
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Choice B: Documenting the injuries is important but reporting to authorities takes precedence in cases of suspected elder abuse.
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Choice D: Taking photographs of the injuries may be helpful for documentation but should not delay reporting to authorities.
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Choice E: Ensuring the client is not left alone with the suspected abuser is important but is not as urgent as reporting the abuse to the authorities.
In conclusion, reporting the findings to the appropriate authorities is the most critical and immediate action to address suspicion of elder abuse.
Extract:
A nurse is admitting an older adult client who was transferring from another facility. The nurse notes pressure ulcers on the clients Coccyx and abrasions around both wrists which of the following actions should the nurse take to address suspicion of elder abuse?
Question 4 of 5
Which actions should the nurse take to address suspicion of elder abuse?
Correct Answer: A,B,C,D,E
Rationale: The correct actions to address suspicion of elder abuse are A, B, C, D, and E.
A: Privately interviewing the client allows for open communication and confidentiality.
B: Documenting injuries in detail provides objective evidence for reporting and potential legal action.
C: Reporting findings to authorities is crucial to protect the elder and comply with legal obligations.
D: Taking photographs, if permitted, supports documentation and investigation.
E: Ensuring the client is not left alone with the suspected abuser protects the client during the assessment. Each action plays a crucial role in addressing elder abuse comprehensively.
Extract:
A nurse is caring for a client
History and Physical
Day 1,0900:
A 52-year-old client brought to emergency department by adult child. Client is alert and oriented
to person and time but does not know where they are. No history of substance use according to
client's adult child. Client exhibits constant movements and poor concentration. Hair and
clothing are unclean, appears to be listening to unseen others. Skin turgor poor.
Nurses Notes
Day 1. 0915
The client's adult child reports the client has not slept for 2 days and has become obsessed with
cleaning the house and hosting parties. At times the client is overly joyous and has a very
elevated sense of self-confidence. The adult child states that the client has also demonstrated
very impulsive spending habits and expresses concern about the client giving away large sums
of money to others
The client's speech is very pressured, disorganized, and loud. Client unable to recall the last time
they ate
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 5 of 5
Select the 4 findings that require immediate follow up
Correct Answer: A,B,C,D
Rationale: The correct answer is A, B, C, and D. Hallucinations (
A) may indicate a serious health issue needing immediate attention. Abnormal heart rate (
B) could signify a cardiac problem. Disrupted sleep patterns (
C) may indicate underlying health conditions. Reduced skin turgor (
D) can signal dehydration or malnutrition.
Choices E, F, and G are not typically indicative of immediate follow-up needs in this context.