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Ati Pn Fundamentals 2023 Proctored Exam
Total Questions : 68
Showing 10 questions, Sign in for moreDay 1, 1100:
Temperature 39.1° C (102.4° F)
Heart rate 102/min
Respiratory rate 26/min
Blood pressure 122/80 mm Hg
Oxygen saturation 86% on room air
Weight 90.7 kg (200 lb)
Day 2, 1200:
Temperature 38° C (100.4° F)
Heart rate 100/min
Respiratory rate 22/min
Blood pressure 120/74 mm Hg
Oxygen saturation 88% on nasal cannula at 2 L/min
Day 3, 1200:
Temperature 37.2° C (99° F)
Heart rate 90/min
Respiratory rate 20/min
Blood pressure 120/72 mm Hg
Oxygen saturation 91% on nasal cannula at 3 L/min
Day 1, 1100:
Client admitted from emergency department with a new diagnosis of pneumonia. Confirmed by chest x-ray and laboratory results. Client reports dyspnea and exhibits shortness of breath at rest. Client is hypoxic, confirmed by oxygen saturation. Placed on oxygen at 2 L/min via nasal cannula.
Congested cough, sputum specimen obtained and sent to the laboratory. Crackles heard on auscultation, breath sounds diminished.
IV initiated in left forearm with 22-gauge angiocath for intermittent antibiotic therapy and further treatment.
Day 2, 1500:
Client remains hypoxic. Less dyspnea noted at rest, extreme shortness of breath noted on exertion. Receiving intermittent IV medications. IV site without manifestations of infection or infiltration.
Day 3, 1500:
Lung sounds clearing, able to take a deeper breath on inspiration. No shortness of breath at rest, still exhibits shortness of breath with exertion. Client is being evaluated for the need for home oxygen therapy.
Day 4, 1500:
Client scheduled for discharge to home.
Reinforced instructions about new home medication prescriptions, including PO antibiotic and steroid.
Reinforced instructions about new home oxygen therapy.
Day 4, 1500:
Discharge prescriptions:
Cephalexin 500 mg PO every 6 hr for 5 days
Prednisone 40 mg PO daily for 5 days
Home oxygen 3 L/min via nasal cannula
A nurse is assisting in the care of a client who has pneumonia.
The nurse is reinforcing discharge teaching with the client and their caregiver. Which of the following information should the nurse include?
Select all that apply.
Day 1:
Collecting client data on food safety.
Raw meats and raw vegetables are prepared together on one cutting board.
Refrigerator is set to 6.7° C (44° F)
Leftovers are discarded after 7 days in refrigerator. Frozen foods are defrosted on the countertop.
Client washes hands for 10 seconds before cooking.
Leftovers are refrigerated after sitting on the countertop for 3 hr.
Reinforced client teaching about food safety. Follow-up visit scheduled in 2 weeks.
Day 14:
At client's home to collect follow-up data on food safety. Uses one cutting board to prepare raw meats and a different cutting board to prepare raw vegetables.
The refrigerator is set to 5.6° C (42° F).
Leftovers are discarded after 2 days in refrigerator.
Frozen foods are defrosted in the refrigerator.
Client washes hands for 15 seconds before cooking.
Leftovers are refrigerated after sitting on the countertop for 2 hr.
A home health nurse is assisting in the care of a client.
Select the 4 findings that indicate an understanding of the reinforced teaching.
Day 1, 1630:
Tympanic temperature 36.6° C (97.8° F)
Respiratory rate 18/min
Heart rate 78/min
Blood pressure 132/84 mm Hg
Oxygen saturation 100% on room air
Day 2, 0815:
Tympanic temperature 37.4° C (99.3° F)
Respiratory rate 20/min
Heart rate 88/min
Blood pressure 152/88 mm Hg
Oxygen saturation 96% on room air
Day 1, 1630:
Mild weakness noted on client's left side. Client reports feeling food stuck in their mouth; vocal quality is somewhat hoarse. Vital signs obtained; will notify provider.
Metoprolol 50 mg PO BID
Simvastatin 40 mg PO daily at bedtime
A nurse in a rehabilitation facility is assisting in the care of a client who was admitted the previous day.
Complete the following sentence by using the list of options.
The client is at risk for
Explanation
Correct answer: The client is at risk for Aspiration as evidenced by the client's Dysphagia.
i. Aspiration: The client is exhibiting classic signs of dysphagia (difficulty swallowing), specifically "feeling food stuck in their mouth" and a "hoarse vocal quality." When a client cannot swallow effectively, food or liquid can enter the airway instead of the esophagus, leading to aspiration pneumonia.
ii. Dysphagia: This is the clinical term for the symptoms described in the Nurses' Notes (hoarseness and food pocketing). While the client does have a slightly elevated blood pressure and heart rate, these are secondary to the primary safety risk of an impaired airway/swallow reflex.
6 months ago:
Client present today for annual examination. Reports lack of sleep and increased stress due to moving and starting a new job.
Today, 1400:
Client presents to office today with reports of fatigue. Client states they have difficulty sleeping without drinking four or five beers a night. Client reports, "I sometimes get headaches along with nausea and vomiting. I have been busy with my new job, so I have been eating a lot of fast food, and I've gained 15 pounds."
Today, 1445:
Provider notified of laboratory results.
6 months ago:
Temperature 37.2° C (99° F)
Heart rate 82/min
Respiratory rate 18/min
Blood pressure 132/68 mm Hg
Oxygen saturation 98% on room air
Today, 1400:
Temperature 36.8° C (98.2° F)
Heart rate 100/min
Respiratory rate 22/min
Blood pressure 162/90 mm Hg
Oxygen saturation 95% on room air
Today, 1445:
Sodium 148 mEq/L (136 to 145 mEq/L)
Potassium 3.7 mEq/L (3.5 to 5 mEq/L)
BUN 16 mg/dL (10 to 20 mg/dL)
Creatinine 0.8 mg/dL (0.5 to 1 mg/dL)
WBC count 8,000/mm3 (5,000 to 10,000/mm3)
HDL 38 mg/dL (greater than 45 mg/dL)
LDL 210 mg/dL (less than 130 mg/dL)
A nurse is assisting in the care of a client in a provider's office.
A nurse is caring for the client. Which of the following prescriptions should the nurse anticipate the provider to prescribe?
Select all that apply.
Upon admission to emergency department (ED), 0945:
Temperature 38.3° C (100.9° F)
Heart rate 102/min
Respiratory rate 22/min
Blood pressure 122/80 mm Hg
Oxygen saturation 96% on room air
Pain reported as 6 on a scale of 0 to 10
Upon admission to medical-surgical department, 1050:
Temperature 38.4° C (101.1° F)
Heart rate 104/min
Respiratory rate 22/min
Blood pressure 124/80 mm Hg
Oxygen saturation 96% on room air
Pain reported as 8 on a scale of 0 to 10
1050:
Received handoff report from the ED nurse for a client who has acute appendicitis and is scheduled for an appendectomy. Client reports that pain began in the mid abdominal region during the night. This morning the pain intensified and localized to the right lower quadrant region. Pain continues to intensify, rebound tenderness noted. Client reports vomiting one time after eating a piece of toast at 0600 with continued feelings of nausea. Peripheral IV to the left forearm with IV fluids infusing.
1200:
Informed consent obtained by the surgeon performing the procedure. Placed in the client's medical record. Client expresses concerns about potential complications that could result from the surgery.
1050:
Received influenza vaccine 1 month ago.
Thyroid disease, taking levothyroxine for 14 years.
History of cholecystectomy 3 years ago.
Denies alcohol or illegal drug use. Reports smoking approximately six cigarettes per day for the past 10 years. Allergic to shellfish, latex, and penicillin.
A nurse is assisting in the care of a client who is scheduled for an appendectomy.
The nurse is assisting with preparing the client for surgery.
Select the 3 findings that require follow-up prior to surgery.
Denies diabetes mellitus or peripheral vascular disease.
1000:
Client is 6 hr postoperative following an appendectomy. Bilateral breath sounds are shallow but clear and present throughout. Abdomen soft, nondistended, bowel sounds hypoactive. Right lower quadrant abdominal dressing dry and intact. Urinary catheter removed in PACU. Client reports pain as 8 on a scale of 0 to 10. Morphine 4 mg IV bolus administered by RN as prescribed. Client wearing sequential compression device.
1200:
Voided 350 mL of clear yellow urine. Abdominal dressing remains dry and intact. Abdomen soft, nondistended, bowel sounds hypoactive. Pedal pulse is even bilaterally, no edema noted in the bilateral extremities. Client drowsy. Reports pain as 2 on a scale of 0 to 10.
1000:
Temperature 36° C (96.8° F)
Blood pressure 118/56 mm Hg Heart rate 92/min
Respiratory rate 18/min
Oxygen saturation 95% on room air
1200:
Temperature 37.2° C (99° F)
Blood pressure 104/56 mm Hg
Heart rate 62/min
Respiratory rate 12/min
Oxygen saturation 94% on room air
A nurse is assisting with the care of a client in a medical-surgical unit.
Select words from the choices below to fill in each blank in the following sentence.
The client is most at risk of developing
Explanation
Correct answer: The client is most at risk of developing atelectasis and paralytic ileus.
Rationale for correct answers:
- atelectasis: The client is 6 hours postoperative, drowsy from morphine, and has shallow breath sounds. Narcotic pain medications suppress the cough reflex and decrease deep breathing, leading to the collapse of alveoli (atelectasis). This is further evidenced by the slight drop in oxygen saturation (95% to 94%) and the decrease in respiratory rate.
- paralytic ileus: The client has hypoactive bowel sounds and has undergone abdominal surgery. General anesthesia and opioid analgesics (morphine) both slow down intestinal motility. If peristalsis does not return or remains severely suppressed, the client can develop a paralytic ileus (a non-mechanical bowel obstruction).
Rationale for incorrect answers:
- urinary tract infection: This is not the primary risk at this time. The client’s urinary catheter was removed, and the client has already successfully voided 350 mL of clear urine, indicating good bladder function and a low immediate risk for UTI.
- delayed wound healing: While a risk for any surgical client, this client denies diabetes and peripheral vascular disease (Exhibit 1), which are the primary risk factors for delayed healing. The dressing is currently dry and intact.
- deep vein thrombosis: Although a general risk for postoperative clients, this client is wearing sequential compression devices (SCDs) and has even pedal pulses with no edema, indicating that preventive measures are in place and working.
The client has a history of a seizure disorder.
0800:
The client is alert and oriented to person, place, and time. Seizure pads placed on the client's bed. Suction equipment is at the client's bedside and functioning. Oxygen equipment is at the client's bedside.
1000:
Client is in bed and reports experiencing an aura, followed by generalized jerking contractions of arms and legs. Client incontinent of urine and unresponsive to commands.
1004:
Client's jerking contractions of arms and legs stopped. Client is confused and lethargic. Bilateral breath sounds clear. Oxygen applied 3 L/min via nasal cannula. Oxygen saturation 95%.
A nurse is assisting in the care of a client.
Complete the following sentence by using the lists of options.
At 1000 the nurse enters the client's room. The first action the nurse should take is
Explanation
Correct answers: At 1000 the nurse enters the client's room. The first action the nurse should take is call for assistance followed by turn the client to their side.
i. call for assistance: According to the nursing process, once a seizure begins (the ictal phase), the nurse must ensure they have help to manage the client's safety and monitor the event. The nurse should stay with the client but call for another staff member to bring emergency equipment or notify the provider.
ii. turn the client to their side: This is the priority safety intervention during a generalized tonic-clonic seizure. Turning the client to a lateral position helps maintain a patent airway and prevents aspiration of oral secretions or vomitus.
Rationale for incorrect answers:
remove the pillows: While removing pillows can help prevent airway occlusion if the head is hyper-flexed, calling for help and positioning the client on their side are higher priorities in the sequence of emergency management.
reorient the client: This occurs during the postictal phase (after the seizure has ended) when the client is regaining consciousness, not during the active seizure at 1000.
administer anticonvulsant medications: While medications like IV lorazepam may be indicated if a seizure is prolonged (status epilepticus), the immediate physical safety and airway management are the first nursing actions.
A nurse in a provider's office is reviewing the medical record of a client who reports having nausea and vomiting for the last 48 hr. Which of the following findings indicate fluid volume deficit? (Select all that apply.)
A nurse is assisting with the care of a client who has cancer that has metastasized. The client has decided to discontinue chemotherapy treatment. Which of the following responses should the nurse make?
A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply.)
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