ATI RN Comprehensive Online Practice
2023 A
A nurse is caring for a client in the emergency department (ED).
0600:
Client presents with acute altered mental status. Client has a history of frequent ED visits for alcohol
intoxication. Client states that they had an episode of binge drinking yesterday afternoon. Client awoke
this morning on the living room floor trembling and flushed; remembers having intense dreams and was
afraid they had a seizure so they called a family member to bring them to the ED.
Client reports their average alcohol intake has been "two or three beers" after work each day and "more
on the weekends" for the past 6 months.
Client reports headache, nausea, agitation, and is noted to be diaphoretic.
0800:
Client states "I've got bugs crawling on me. Get them off me!" Client tremulous and diaphoretic.
History and Physical:
Alcohol use disorder
Delirium tremens
Nicotine use disorder
Hypertension, diet and exercise controlled.
Vital Signs
0 - a. Initiate seizure precautions
c. Perform a Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar)
d. Administer chlordiazepoxide
e. Maintain a low-stimulation environment
f. Administer thiamine
,an RN is observing a licensed practical nurse LPN and an assistive personnel AP move a client up in bed.
for which of the following situations should the nurse intervene? - The LPN and the AP grasp the client
under their arms to lift him up in bed.
This can result in shoulder dislocation or other injury to the client.
A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of
the following interventions should the nurse include in the plan? - Support the client's left arm on a
pillow while sitting.
Prevents the extremity from hanging freely because this can cause shoulder subluxation.
A nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in
multiple joints. Which of the following actions should the nurse plan to take? - Allow for frequent rest
periods throughout the day.
A nurse is caring for a client who has bipolar disorder. The nurse observes that the client is becoming
increasingly restless. The client is pacing the unit and speaking rapidly, frequently using profanities and
sexual references. Which of the following actions should the nurse take first? - Move the client to a
quiet place away from others.
A nurse is caring for a client who has a terminal illness and requests no lifesaving measures if a cardiac
arrest occurs. Which of the following statements should the nurse make? - "I will provide you with
information about medical treatment to include in your living will."
A nurse is assess a 2-month-old infant during a well-baby examination. Which of the following actions
should the nurse take to assess the infant's rooting reflex? - Stroke the infant's cheek
A nurse is assessing a client following a colonoscopy. Which of the following findings should indicate to
the nurse that the client is hemorrhaging? - Rapid decrease in blood pressure
, A nurse is assessing a client who is taking propranolol. Which of the following findings should indicate to
the nurse that this client is experiencing an adverse reaction to propranolol? - Wheezing
A client who is 24 hours postoperative following abdominal surgery refuses to ambulate. Which of the
following actions should the nurse take first? - Ask the client to rate their pain level
A nurse is assessing a preschooler who has cystic fibrosis and has been receiving oxygen therapy for the
past 36 hr. Which of the following findings should the nurse identify is an indication that the client has
developed oxygen toxicity? - Substernal pain
A charge nurse observes a staff nurse document a dressing change in a client's chart that was not
performed. Which of the following actions should the charge nurse take first? - Gather more
information about the staff nurse's actions
A nurse manager is on a planning committee to develop an emergency preparedness plan. The nurse
should recommend that which of the following actions takes place first when implementing an
emergency preparedness plan? - Notify the incident commander
A nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after falling
off a step stool at home. Which of the following prescriptions should the nurse clarify with the provider?
- Apply a cold pack to the client's ankle for 30 min every hour
A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse
expect? - Rapid speech
A nurse is assessing a client for compartment syndrome. Which of the following findings should the
nurse expect? - Edema
2023 A
A nurse is caring for a client in the emergency department (ED).
0600:
Client presents with acute altered mental status. Client has a history of frequent ED visits for alcohol
intoxication. Client states that they had an episode of binge drinking yesterday afternoon. Client awoke
this morning on the living room floor trembling and flushed; remembers having intense dreams and was
afraid they had a seizure so they called a family member to bring them to the ED.
Client reports their average alcohol intake has been "two or three beers" after work each day and "more
on the weekends" for the past 6 months.
Client reports headache, nausea, agitation, and is noted to be diaphoretic.
0800:
Client states "I've got bugs crawling on me. Get them off me!" Client tremulous and diaphoretic.
History and Physical:
Alcohol use disorder
Delirium tremens
Nicotine use disorder
Hypertension, diet and exercise controlled.
Vital Signs
0 - a. Initiate seizure precautions
c. Perform a Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar)
d. Administer chlordiazepoxide
e. Maintain a low-stimulation environment
f. Administer thiamine
,an RN is observing a licensed practical nurse LPN and an assistive personnel AP move a client up in bed.
for which of the following situations should the nurse intervene? - The LPN and the AP grasp the client
under their arms to lift him up in bed.
This can result in shoulder dislocation or other injury to the client.
A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of
the following interventions should the nurse include in the plan? - Support the client's left arm on a
pillow while sitting.
Prevents the extremity from hanging freely because this can cause shoulder subluxation.
A nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in
multiple joints. Which of the following actions should the nurse plan to take? - Allow for frequent rest
periods throughout the day.
A nurse is caring for a client who has bipolar disorder. The nurse observes that the client is becoming
increasingly restless. The client is pacing the unit and speaking rapidly, frequently using profanities and
sexual references. Which of the following actions should the nurse take first? - Move the client to a
quiet place away from others.
A nurse is caring for a client who has a terminal illness and requests no lifesaving measures if a cardiac
arrest occurs. Which of the following statements should the nurse make? - "I will provide you with
information about medical treatment to include in your living will."
A nurse is assess a 2-month-old infant during a well-baby examination. Which of the following actions
should the nurse take to assess the infant's rooting reflex? - Stroke the infant's cheek
A nurse is assessing a client following a colonoscopy. Which of the following findings should indicate to
the nurse that the client is hemorrhaging? - Rapid decrease in blood pressure
, A nurse is assessing a client who is taking propranolol. Which of the following findings should indicate to
the nurse that this client is experiencing an adverse reaction to propranolol? - Wheezing
A client who is 24 hours postoperative following abdominal surgery refuses to ambulate. Which of the
following actions should the nurse take first? - Ask the client to rate their pain level
A nurse is assessing a preschooler who has cystic fibrosis and has been receiving oxygen therapy for the
past 36 hr. Which of the following findings should the nurse identify is an indication that the client has
developed oxygen toxicity? - Substernal pain
A charge nurse observes a staff nurse document a dressing change in a client's chart that was not
performed. Which of the following actions should the charge nurse take first? - Gather more
information about the staff nurse's actions
A nurse manager is on a planning committee to develop an emergency preparedness plan. The nurse
should recommend that which of the following actions takes place first when implementing an
emergency preparedness plan? - Notify the incident commander
A nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after falling
off a step stool at home. Which of the following prescriptions should the nurse clarify with the provider?
- Apply a cold pack to the client's ankle for 30 min every hour
A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse
expect? - Rapid speech
A nurse is assessing a client for compartment syndrome. Which of the following findings should the
nurse expect? - Edema
