ATI RN
ATI Fundamentals Proctored Exam 2023
1. During the assessment of a client receiving packed RBCs, which finding indicates fluid overload?
- A. Low back pain.
- B. Dyspnea.
- C. Hypotension.
- D. Thready pulse.
Correct answer: B: Dyspnea.
Rationale: Dyspnea is a key finding indicating fluid overload in a client receiving packed RBCs. Fluid overload can lead to pulmonary edema, causing difficulty breathing or shortness of breath (dyspnea). Low back pain is not typically associated with fluid overload but can be more related to musculoskeletal issues. Hypotension and thready pulse are more indicative of hypovolemia (low fluid volume), not fluid overload.
2. A nurse is assessing a client who is in the first stage of labor and has an external fetal monitor in place. The nurse observes early decelerations in the fetal heart rate. Which of the following actions should the nurse take?
- A. Continue to monitor the fetal heart rate
- B. Reposition the client
- C. Administer oxygen via face mask
- D. Increase the rate of the IV fluids
Correct answer: A
Rationale: Early decelerations are a benign finding that typically indicate fetal head compression, a normal response to uterine contractions. They do not require intervention as they are not associated with fetal compromise. The appropriate action for the nurse in this scenario is to continue to monitor the fetal heart rate. Repositioning the client, administering oxygen, or increasing IV fluids are not indicated responses to early decelerations and could be unnecessary or potentially harmful.
3. A nurse in an emergency department completes an assessment on an adolescent client with conduct disorder. The client threatened suicide to a teacher at school. Which of the following statements should the nurse include in the assessment?
- A. Tell me about your siblings
- B. Tell me what kind of music you like
- C. Tell me how often you drink alcohol
- D. Tell me about your school schedule
Correct answer: C
Rationale: Asking about alcohol intake is crucial in assessing the client's risk factors and behaviors, especially in the context of a suicide threat. Understanding alcohol consumption patterns can help the nurse evaluate potential substance abuse issues and their impact on the client's mental health. Choices A, B, and D are less pertinent to the immediate concern of assessing suicide risk and conduct disorder symptoms.
4. A patient with a history of venous thromboembolism is prescribed hormone replacement therapy (HRT). What should the nurse emphasize about the risks associated with this therapy?
- A. HRT is associated with an increased risk of venous thromboembolism, so patients should be educated about the signs and symptoms of blood clots.
- B. HRT may improve mood and energy levels, but it also increases the risk of osteoporosis.
- C. HRT can decrease the risk of fractures, but it also increases the risk of developing diabetes.
- D. HRT may increase the risk of breast cancer, so regular mammograms are essential.
Correct answer: A
Rationale: HRT is associated with an increased risk of venous thromboembolism, so patients should be educated about the signs and symptoms of blood clots and advised to seek immediate medical attention if they occur.
5. A child is being cared for following a head injury. Which of the following findings should indicate to the healthcare provider that the child is developing diabetes insipidus?
- A. Urine specific gravity of 1.045
- B. Sodium level of 155
- C. Blood glucose level of 45
- D. Urine output of 35 ml per hour
Correct answer: B
Rationale: In a child with a head injury, the development of diabetes insipidus can occur due to pituitary hypofunction, leading to a deficiency of antidiuretic hormone. An elevated sodium level (hypernatremia) is a key finding in diabetes insipidus due to the excessive loss of free water in the urine, resulting in increased sodium concentration in the blood.
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