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ATI Clinical Exam
Total Questions : 117
Showing 10 questions, Sign in for moreThe client appears fatigued and reports a persistent headache. He has been experiencing muscle aches throughout his body. He also complains of a sore throat and has had a fever for the past two days. The client’s skin is warm to the touch and he appears slightly dehydrated.
- Temperature: 39.5°C (103.1°F)
- Blood pressure: 128/56 mm Hg
- Heart rate: 112/min
- Respiratory rate: 22/min
- SaO2: 96% on room air
- Complete blood count shows elevated white blood cells
- Throat culture has been sent to the lab for analysis
- Chest X-ray pending
A nurse is caring for a 45-year-old male client in the emergency department. The client was admitted at 0700hrs with a 2-day history of headache, muscle aches, fever, sore throat, and fatigue.
The nurse is preparing to administer an antibiotic to the client. Which of the following actions should the nurse take? (Select all that apply)
- The client arrived in the emergency department with complaints of fatigue, blurred vision, dizziness, and headache for the past two days. They report running out of blood glucose strips and insulin due to financial constraints. The client appears tired, is cooperative, and has a slightly dry mucous membrane. They are oriented to person, place, and time but seem concerned about their health status. The skin is warm and dry to the touch, with no visible rashes or lesions. Heart sounds are regular without murmurs; breath sounds are clear bilaterally. The abdomen is soft with no tenderness upon palpation. The client expresses anxiety about potential falls due to dizziness.
- Blood Pressure: 120/72 mm Hg
- Temperature: 36.8° C (98.2° F)
- Pulse: 88/min
- Respirations: 20/min
- Blood Glucose: 235 mg/dL (Reference range: 74-106 mg/dL)
- HbA1c: 8.4% (Target for diabetics: <7%)
- Hemoglobin: 14.2 g/dL (12-18 g/dL)
- Hematocrit: 42.6% (37-52%)
- WBC Count: 6000/mm³ (5000-10,000/mm³)
- Increase glargine from 20 units to 25 units at bedtime.
- Continue other home medications as prescribed.
Scenario: A nurse is caring for a client admitted to the medical-surgical unit. The exhibits below detail the client's condition at different time points throughout the day. Review the exhibits and determine how the patient's condition evolves and whether it worsens or improves. The initial data is recorded at 0700 hrs, followed by subsequent observations at different times.
Based on the initial assessment and diagnostic results, what is the priority nursing intervention?
- The client is found attempting to climb out of bed, stating, "People are trying to hurt me." They are highly agitated and disoriented, attempting to remove IV lines. The client's behavior is erratic, and they require constant supervision. The skin is now cool and pale, with poor capillary refill. Respirations are labored, and the client is using accessory muscles to breathe. Lung sounds have deteriorated, with coarse crackles heard throughout. The abdomen is firm, and the client expresses significant discomfort. The urinary catheter output has decreased, and urine appears concentrated.
- Blood Pressure: 100/64 mm Hg
- Temperature: 37.3° C (99.1° F)
- Pulse: 110/min
- Respirations: 28/min
- Hemoglobin: 12.5 g/dL
- Hematocrit: 38.0%
- AST: 52 units/L
- ALT: 49 units/L
- Soft wrist restraints if necessary.
- Immediate reassessment and adjustment of care plan.
2100 hrs - Critical Incident
A nurse is providing discharge teaching to a client recently diagnosed with a latex allergy. Which of the following client statements indicates a need for further teaching?
- The client has been lying in bed and appears more fatigued than earlier. They complain of increased dizziness and a persistent headache. The nausea has worsened, and the client reports feeling faint upon sitting up. There is noticeable pallor, and the skin feels cool to touch. The client is breathing rapidly and appears anxious, stating that they feel something is not right. Heart rate has increased further, and rhythm remains regular but fast. Lung sounds are now clear bilaterally without diminished areas. The client still requires assistance for ambulation due to unsteadiness.
- Blood Pressure: 110/68 mm Hg
- Temperature: 36.4° C (97.5° F)
- Pulse: 98/min
- Respirations: 24/min
- Hemoglobin: 13.4 g/dL
- Hematocrit: 40.8%
- Blood Glucose: 245 mg/dL
- Serum Potassium: 4.8 mEq/L (Reference range: 3.5-5.0 mEq/L)
- Administer IV fluids at 75 mL/hr.
- Recheck blood glucose level in 2 hours.
- Continue monitoring fluid intake and output.
Scenario
A nurse is caring for a client admitted to the medical-surgical unit. The exhibits below detail the client's condition at different time points throughout the day. Review the exhibits and determine how the client's condition evolves and whether it worsens or improves.
1500 hrs - Follow-Up Assessment
Based on the 1500 hrs assessment, categorize the following actions for the client.
Explanation
|
Action |
Essential |
Nonessential |
Contraindicated |
|
Increasing IV fluid rate |
The current rate is prescribed by the provider; increasing it without further assessment could lead to complications. |
||
|
Encouraging the client to sit up without assistance |
The client feels faint upon sitting up and is unsteady, so this could be dangerous. |
||
|
Administering antiemetic medication |
Helpful but not immediately critical. |
||
|
Monitoring respiratory rate closely |
Crucial due to client's rapid breathing and anxiety. |
||
|
Providing reassurance and calming interventions |
Important due to client's anxiety and discomfort. |
||
|
Checking electrolyte levels regularly |
Essential for ongoing monitoring given the client's symptoms. |
||
Essential
-
Monitoring respiratory rate closely: The client is breathing rapidly and appears anxious, making close monitoring crucial to ensure timely intervention and management of respiratory issues.
-
Providing reassurance and calming interventions: The client is anxious and discomforted. Providing reassurance and calming interventions is important to address their immediate emotional and psychological needs.
-
Checking electrolyte levels regularly: Given the client's symptoms and the need for ongoing monitoring, checking electrolyte levels is essential for managing their condition effectively.
Nonessential
- Administering antiemetic medication: While helpful for managing nausea, this action is not immediately critical compared to other interventions that address more urgent needs.
Contraindicated
-
Encouraging the client to sit up without assistance: The client feels faint and is unsteady when sitting up. Encouraging them to sit up without assistance could be dangerous and may increase the risk of falls or injuries.
-
Increasing IV fluid rate: The current IV fluid rate is prescribed by the provider. Increasing it without further assessment could lead to complications and should be avoided unless directed by a healthcare provider.
Date: 06/28/0X
- Client presented to the clinic reporting pelvic pain, dysmenorrhea, dyspareunia, and pain with defecation.
- Vaginal examination reveals fixed, palpable nodules with a retroverted uterus.
- Imaging reveals endometrial lesions on the ovaries, uterosacral ligaments, and round ligaments.
- Endometriosis diagnosed.
- Nafarelin 200 mcg: 1 spray intranasally every morning and 1 spray in the opposite nostril every evening.
- Client reports adherence to nafarelin regimen without missing doses.
- Client verbalizes irritation in the nasal mucosa.
- Reports feeling better overall with decreased dyspareunia.
- Notes decreased pain during bowel movements.
- Reports decreased pelvic pain and the absence of menstruation last month.
- Mentions experiencing headaches, increased acne, and reduced sex drive since starting treatment.
- Client observes a decrease in breast size.
Scenario:
A nurse is caring for a 32-year-old female client who was recently diagnosed with endometriosis. The client is in the clinic for a follow-up visit after beginning nafarelin treatment.
Setting: Clinic
Which of the following manifestations reported by the client should the nurse identify as a therapeutic effect of the nafarelin? (Select all that apply.)
- Gestational age: 42 weeks
- Delivery: Spontaneous vaginal birth
- Amniotic fluid: Dark brown-greenish color noted
- Apgar scores: 8 at 1 minute, 9 at 5 minutes
- Axillary temperature: 36.9°C (98.4°F)
- Heart rate: 170/min
- Respiratory rate: 72/min
- Birth weight: 4025 gm (8 lb 14 oz) (Appropriate for Gestational Age)
The newborn was placed on the birth parent's abdomen immediately following delivery. The mouth and nose were suctioned with a bulb syringe to clear secretions. The newborn was dried and stimulated, resulting in a strong cry. The newborn was moving all extremities with a flexed tone noted. Acrocyanosis was present. The newborn was alert and active. Respirations were rapid and shallow with occasional expiratory grunting. Fine crackles were auscultated throughout the lung fields. A small amount of green- stained vernix was present in skin folds. The newborn had fingernails stained green. Molding of the skull and generalized soft occipital swelling were noted.
A nurse is caring for a newborn who is 30 minutes old following a spontaneous vaginal birth. The birth parent noted dark brown- greenish amniotic fluid during labor. The newborn was delivered at 42 weeks gestation. Apgar scores were 8 at 1 minute and 9 at 5 minutes.
After reviewing the information in the newborn's medical record, which of the following complications should the nurse identify as posing the greatest risk? Drag one condition and one client finding to fill in each blank in the following sentence.
The condition that poses the greatest risk to the newborn is
Explanation
The condition that poses the greatest risk to the newborn is Meconium aspiration syndrome due to color of amniotic fluid.
Meconium aspiration syndrome is a serious condition that can occur when a newborn inhales a mixture of meconium (the first stool) and amniotic fluid into the lungs around the time of delivery. The dark brown-greenish color of the amniotic fluid indicates the presence of meconium, which increases the risk of this condition.
- 1700: Dextrose 5% in 0.45% sodium chloride (D5/0.45% NaCl) at 100 mL/hr
- 1700: Promethazine 25 mg IV bolus every 4 hours PRN for nausea/vomiting
- 1715: Morphine 4 mg IV bolus every 6 hours PRN for pain
- 2115: Acetaminophen 625 mg PO every 6 hours PRN if temperature > 38.6°C (101.5°F)
- Discontinue Morphine (Note: The morphine has not yet been administered as the order is due in the future.)
The client was received from the Post Anesthesia Care Unit (PACU) with initial vital signs recorded. The client is drowsy but arouses to verbal stimuli and is oriented to person, place, and time. The client is able to move all extremities and follow simple commands.
The heart rhythm is normal sinus, bilateral radial and pedal pulses are +2, and capillary refill is less than 2 seconds. Respiratory rate is 18/min with clear lung sounds and oxygen saturation of 96% on 2 L via nasal cannula. Bowel sounds are hypoactive in all four quadrants. The indwelling urinary catheter is draining clear yellow urine. The dressing on the right knee is dry and intact, with no drainage noted.
At 1830, the client was repositioned for comfort with side rails up x2 and the call light within reach. The client remains somewhat lethargic but arouses easily and reports nausea and pain, rating the pain as 6 on a scale from 0 to 10. Metoclopramide 10 mg IV was administered at 1830 for nausea. The client is positioned comfortably with the side rails up and call light within reach.
- Heart Rate: 88/min
- Respiratory Rate: 18/min
- Blood Pressure: 115/55 mm Hg
- Temperature: 36.4°C (97.5°F)
- Oxygen Saturation: 96% on 2 L via nasal cannula
- General Behavior: Drowsy but arouses easily, somewhat lethargic
- Pain Level: Rated as 6 on a scale from 0 to 10
- Bowel Sounds: Hypoactive in all four quadrants
- Urinary Output: Clear yellow urine from indwelling catheter
- Knee Dressing: Dry and intact with no drainage
A nurse is caring for a client who is 6 hours postoperative following a right knee arthroplasty. The client has been receiving medications and fluids as outlined below.
Complete the following sentence by selecting the most appropriate action from the choices below:
The nurse should first:
Explanation
The nurse should first: C. Administer additional morphine for pain management, followed by B. Reposition the client for comfort.
The client is reporting a pain level of 6 on a scale from 0 to 10, which indicates moderate to severe pain. As per the medication administration record, the client has an order for Morphine 4 mg IV bolus every 6 hours PRN for pain. Since the client is in pain, it would be appropriate to administer the morphine first to manage the pain.
After addressing the client’s pain, the nurse should then reposition the client for comfort. This can help to alleviate any discomfort or pressure points that may be contributing to the client’s pain. It’s also important to ensure the client’s safety and comfort by making sure the call light is within reach.
The options related to restraints (A and D for Response 1, and A, B, C, D for Response 2) are not relevant in this scenario as there is no indication in the provided information that the client is being restrained or that restraints are necessary. The client is drowsy but arouses easily to verbal stimuli and is able to follow simple commands, suggesting that they are not at risk of harming themselves or others, which would necessitate the use of restraints. Therefore, these options can be ruled out.
Which statement from the parent indicates a correct understanding of the teaching?
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