ATI RN
ATI RN Comprehensive Predictor 2023 Updated Questions
Extract:
1&0
Admission assessment
1900:
L intake over 12 hr
750 mL urine output over 12 hr
650 m
Question 1 of 5
Which of the following actions should the nurse take to decrease the risks for urinary tract infection for this client? Select all that apply.
Correct Answer: A,B,F
Rationale:
Correct
Answer: A, B, F
Rationale:
A: Reviewing the need for the indwelling catheter helps to assess if it can be removed, reducing UTI risk.
B: Encouraging adequate fluid intake promotes urinary flow, flushing out bacteria and reducing UTI risk.
F: Using soap and water for perineal care reduces bacteria, decreasing UTI risk.
Incorrect
Choices:
C: Placing the drainage bag on the bed during transport increases the risk of contamination.
D: Waiting for the bag to be half-full before emptying can lead to backflow of urine, increasing UTI risk.
E: Changing the catheter tubing every 3 days is unnecessary and may introduce new bacteria, increasing UTI risk.
Summary:
The correct actions focus on preventing the introduction and growth of bacteria, while the incorrect choices may increase the risk of urinary tract infections through improper handling and care.
Extract:
Nurses' notes
0900:
A 16-year-old client reports to the clinic with their caregiver. The client's caregiver informs the nurse that the client has "not been themselves lately." The client's parents and a sibling passed away from injuries sustained when a tornado moved through their town 1 month ago. They were the only survivor and witnessed their family's deaths.
0910:
Client appears anxious but answers questions appropriately for age. They report experiencing nightmares that awaken them at night and startle easily during thunderstorm, but the client admits that they have always been afraid of thunderstorms. Client admits smoking marijuana for about 1 month because it helps clear their mind. They also admit that they have no desire to leave the house. They do attend school regularly and are on the honor roll.
Question 2 of 5
Based on the information in the client's medical record, which of the following findings require immediate follow-up? Select the 4 findings that require follow-up.
| Smoking marijuana to clear their mind |
| BP 122/80 mm Hg |
| Witnessing their family's death |
| Attends school regularly |
| Client experiences nightmares |
| Startles easy during thunderstorm |
| Caregiver reporting client acting differently than usual |
Correct Answer: A,C,E,F,H
Rationale: Given the scenario, immediate follow-up is needed for findings that may indicate potential risks or issues.
A: Smoking marijuana for mental clarity can indicate substance abuse and potential mental health concerns.
C: Witnessing family's death can lead to psychological trauma and requires emotional support.
E: Experiencing nightmares could indicate underlying psychological distress or trauma.
F: Startling easily during a thunderstorm may indicate heightened anxiety or PTSD symptoms.
H: Caregiver reporting client acting differently suggests a change in behavior that needs assessment.
Other choices are not as urgent:
B: BP within normal range, not an immediate concern.
D: Attending school regularly is positive.
Extract:
Nurses' notes
Vital Signs
Laboratory results
0900:
The client reports experiencing a loss of appetite and shortness of breath within the last month or so. The client reports experiencing weakness, abdominal pain, severe itching, and mood changes. The client has had alcohol use disorder for the past 10 years and sometimes drinks alcohol uncontrollably.
The client is alert but disoriented to time. Their abdomen is bloated and they have redness of the palms of the hands. Excoriated areas on the upper thorax and shoulders are present. Sclera are yellow.
1230:
Administered antacids, spironolactone, and colchicine per provider's prescription
Question 3 of 5
Select the 5 actions the nurse should take.
| Restrict the client's sodium intake. |
| Provide frequent rest periods for the client. |
| Assess the client's level of orientation. |
| Instruct the client to avoid blowing their nose forcefully. |
| Place the client on a low-carbohydrate diet. |
| Place the client under contact isolation. |
| Advise the client to avoid the use of soap and alcohol-based lotions. |
Correct Answer: A,B,C,G
Rationale: [1, 0, 1, 0, 0, 0, 1]
To select the 5 correct actions, the nurse should:
A: Restricting sodium intake is crucial for clients with certain health conditions.
B: Providing rest periods helps with client recovery and energy conservation.
C: Assessing orientation is essential for monitoring cognitive function.
G: Advising against soap and alcohol-based lotions prevents skin irritation.
Incorrect choices:
D: Avoiding forceful nose blowing is not among the top priorities for the nurse.
E: Placing the client on a low-carb diet is not mentioned as a necessary action.
F: Placing the client under contact isolation is not warranted based on the scenario.
Extract:
Vital signs
0600:
Temperature 37.2° C (99° F)
Heart rate 66/min
Respiratory rate 16/min
BP 130/82 mm Hg
Pulse oximetry 96% on room air
1000:
Temperature 37.6° C (99.7° F)
Heart rate 70/min
Respiratory rate 20/min
BP 160/102 mm Hg
Pulse oximetry 96% on room air
Client reports pain as 10 on a scale of 0 to 10 from headache
Question 4 of 5
For each potential nursing action, click to specify if the action is anticipated or contraindicated for the client.
| Options | Anticipated | Contraindicated |
|---|---|---|
| Perform suctioning | ||
| Withhold pain medication for headache until other manifestations resolve | ||
| Assess blood pressure every 15 minutes | ||
| Administer nifedipine | ||
| Assess for urinary retention | ||
| Place client in supine position |
Correct Answer: C,E
Rationale: [0,0,1,0,1,0,0]
Performing suctioning is not indicated unless there is a clear need for airway clearance. Withholding pain medication (option
B) for headache may worsen the client's discomfort. Administering nifedipine (option
D) should not be done without proper assessment and prescription. Placing the client in the supine position (option F) may not be ideal depending on the client's condition. Assessing blood pressure (option
C) is important for monitoring the client's status, especially after a head injury. Assessing for urinary retention (option E) is also crucial to ensure proper bladder function and prevent complications.
Extract:
Nurses' notes
Day 1
1400:
Client has paraplegia and reports, "I have had a cough the last few days. I haven't had an appetite either." Denies nausea, vomiting, or diarrhea. Alert and oriented to person, place, and time. Skin is intact. Vital signs stable.
Day 2
1830:
Client is experiencing tachycardia, productive cough, and confusion
Question 5 of 5
Complete the following sentence by using the list of options.
| hypostatic pneumonia |
| anemia |
| fluid volume overload |
| orthostatic hypotension |
| calorie deficiency |
Correct Answer: A
Rationale:
To determine the correct answer, consider the term "hypostatic pneumonia." Hypostatic pneumonia is a type of pneumonia that occurs when a person is immobile for an extended period, leading to fluid buildup in the lungs. This condition is often seen in bedridden individuals or those with limited mobility. In the context of the question, the term "hypostatic pneumonia" fits logically as a consequence of immobility or prolonged bed rest, making it the correct answer.
Now, let's evaluate the other options:
- Anemia : Anemia is a condition characterized by a lack of healthy red blood cells or hemoglobin, which is not directly related to immobility.
- Fluid volume overload (
C): This condition involves excess fluid in the body, which is not specifically linked to immobility.
- Orthostatic hypotension (
D): Orthostatic hypotension is a drop in blood pressure that occurs when standing up, not solely associated with immobility