ATI Central Arizona College

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Sample questions from ATI Central Arizona College

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.A 68-year-old client is admitted to a medical-surgical unit with pneumonia. The client is restless and newly confused, with a temperature of 38.6 C (101.5 F), heart rate 118/min, respiratory rate 30/min, blood pressure 88/54 mm Hg, and oxygen saturation 89% on room air. Which action should the nurse take first?

   • A.Apply supplemental oxygen and activate the rapid response system
   • B.Obtain a sputum specimen before starting treatment
   • C.Give the prescribed antipyretic
   • D.Encourage oral fluids and recheck the vital signs in 30 minutes

   Rationale: The client has hypoxemia, hypotension, tachycardia, and acute mental-status change, so immediate support and escalation are needed for possible sepsis and respiratory compromise. Obtaining a sputum specimen is useful but must not delay stabilization. An antipyretic does not address the immediate threats, and waiting while encouraging fluids is unsafe with these signs of deterioration.

2. 2.A 72-year-old client with heart failure is receiving furosemide and reports weakness. The client has a potassium level of 2.9 mEq/L, heart rate 104/min, and occasional premature ventricular contractions on telemetry. Which action is the priority?

   • A.Administer the scheduled furosemide
   • B.Notify the health care provider and anticipate potassium replacement
   • C.Encourage the client to walk in the hallway
   • D.Restrict dietary potassium

   Rationale: Severe hypokalemia with ventricular ectopy creates a risk for life-threatening dysrhythmia, so the nurse should promptly report the findings and anticipate replacement. Giving furosemide could worsen potassium loss. Walking is not the priority while ectopy is present, and restricting potassium would aggravate the abnormality.

3. 3.A 54-year-old client with type 1 diabetes is diaphoretic and confused before lunch. The capillary glucose is 48 mg/dL, and the client can swallow safely. Which action should the nurse take?

   • A.Give 15 g of a rapid-acting oral carbohydrate and recheck glucose in 15 minutes
   • B.Administer the scheduled rapid-acting insulin
   • C.Give a high-protein snack and recheck glucose in 1 hour
   • D.Withhold all food until the client is fully alert

   Rationale: A conscious client who can swallow should receive a rapid-acting carbohydrate, followed by a glucose recheck in 15 minutes and repeat treatment if needed. Insulin would further lower the glucose. Protein acts too slowly for initial treatment, and withholding food would worsen hypoglycemia.

4. 4.A 63-year-old client with diabetes is admitted with vomiting and abdominal pain. The client has deep, rapid respirations, a glucose of 468 mg/dL, potassium of 5.4 mEq/L, and positive serum ketones. Which prescribed intervention should the nurse implement first?

   • A.Begin the prescribed isotonic IV fluid bolus
   • B.Administer subcutaneous long-acting insulin
   • C.Provide oral fluids and a carbohydrate snack
   • D.Administer sodium bicarbonate without reviewing the pH

   Answer and rationale are in the full material.

5. 5.A 76-year-old client with a urinary infection becomes febrile and confused. Temperature is 39.1 C (102.4 F), heart rate 122/min, blood pressure 84/48 mm Hg, and lactate is 4.2 mmol/L. Which action should the nurse prioritize?

   • A.Obtain ordered cultures promptly and initiate the sepsis protocol, including prescribed fluids and antibiotics
   • B.Wait for culture results before administering antibiotics
   • C.Give an oral antipyretic and reassess in 1 hour
   • D.Place the client in a quiet room to reduce confusion

   Answer and rationale are in the full material.