2023 ATI RN CONCEPT BASED ASSESSMENT LEVEL 2
PROCTORED EXAM ACTUAL EXAM TEST BANK 300
QUESTIONS AND CORRECT DETAILD ANSWERS WITH
RATIONALES (VERIFIED ANSWERS) |ALREADY
GRADED A+
A nurse is caring for a client who has developed cellulitis in a lower
extremity. Which of the following actions should the nurse take?
-Apply warm dary packs initially then apply cool moist packs to the
lower extremity
-Elevate the extremity 7.6 to 15.2 cm above heart level
-Gently massage the affected extremity for 10-15 min every shift
-Apply a topical corticosteroid to any open areas on the affected
extremity twice per day – ANSWER- Elevate the extremity 7.6 to 15.2
cm above heart level
Rationale: The nurse should elevate the client’s affected extremity 7.6
to 15.2 cm (3 to 6 in) above the heart to promote venous return and
decrease edema.
A nurse is teaching about ezetimibe with a client who has
hyperlipidemia. Which of the following client statements indicates an
understanding of the teaching?
-I should avoid this medication with milk
-I will return to have my cholesterol levels checked in 2 weeks
-I can expect to lose weight while taking this medication
-I understand that muscle tenderness is an expected result of this
medication – ANSWER- I will return to have my cholesterol levels
checked in 2 weeks
A nurse is monitoring a client who has metabolic acidosis due to
salicylate overdose. For which of the following findings should the nurse
monitor?
-Flushed, dry skin
-Seizures
-Hyperreflexia
-Positive Trousseau’s sign – ANSWER- Flushed, dry skin
Rationale: The nurse should monitor a client who has metabolic
acidosis for manifestations of warm, flushed, and dry skin due to
vasodilation from an increased respiratory rate and the loss of CO2.
A nurse in an emergency department is caring for a client who has
appendicitis. Which of the following actions should the nurse take?
-restrict oral intake to clear fluids
-place a heating pad on the client’s abdomen
-place the client in semi-Fowler’s position
-Administer an enema – ANSWER- Place the client in semi-Fowler’s
position
Rationale: The nurse should place the client in semi-Fowler’s position
to contain abdominal drainage in the lower abdomen and prevent it from
seeping into the peritoneum.
A nurse is reviewing a client’s home medication list during admission to
a long-term care facility. The nurse should identify that the client takes
which of the following medications to manage osteoarthritis? Select all
that apply – ANSWER- Lidocaine 5% patches, Celecoxib,
Cyclobenzaprine, Glucosamine
A nurse is assessing a client who has renal calculi. For which of the
following findings should the nurse notify the provider immediately?
-Flank pain with radiation toward the scrotum
-150 mL emesis
-Oliguria with bladder distention
-Blood pressure 160/90 mmHg – ANSWER- Oliguria with bladder
distention
Rationale: The greatest risk to this client is injury due to bladder
obstruction as indicated by decreased urinary output in the presence of
bladder distention. The calculi can create an obstruction of the bladder
neck or urethra. The nurse should identify this as a medical emergency
and notify the provider immediately.
A nurse is reviewing the laboratory results of a client who is taking
sulfasalazine to treat ulcerative colitis. Which of the following
laboratory findings should the nurse identify as an adverse effect of
sulfasalazine?
-Total bilirubin 0.8 mg/dL
-WBC count 4,000/mm^3
-Platelets 190,000/mm^3
-Creatinine 1 mg/dL – ANSWER- WBC count 4,000/mm^3
Rationale: Agranulocytosis, or a very low WBC count, is an adverse
effect of sulfasalazine. This condition results in a decreased WBC count.
The nurse should identify that a WBC count of 4,000/mm3 is less than
the expected reference range of 5,000 to 10,000/mm3, indicating an
adverse effect of the medication.
A nurse is assessing an infant whose guardian reports, “My baby has
been crying nonstop, has a fever, and has been pulling at her ear.” Which
of the following manifestations should the nurse expect for an infant
who might have otitis media ?
-Enlarged postauricular lymph nodes
-Increased flatulence with constipation
-Indicates a desire to such more frequently
-Slow bounding heart rate – ANSWER- Enlarged postauricular lymph
nodes
Rationale: The nurse should expect an infant who has otitis media to
have enlarged postauricular and cervical lymph nodes, fever, pain,
rhinorrhea, vomiting, and diarrhea. The fever might be as high as 40° C
(104° F).
A nurse is reviewing the laboratory results of an adult male client who
has hyperlipidemia and is making lifestyle changes to improve his
cholesterol levels. Which of the following findings indicates to the nurse
that the client has achieved a therapeutic response?
-LDL 168 mg/dL
-HDL 50 mg/dL
-Total cholesterol 268 mg/dL
-Triglycerides 250 mg/dL – ANSWER- HDL 50 mg/dL
Rationale: This finding indicates that the client has achieved a
therapeutic response from a lifestyle change because the HDL is within
the expected reference range of greater than 45 mg/dL for an adult male
client.
A nurse is assessing a client who is experiencing diarrhea and vomiting
and has a sodium level of 124 mEq/L. Which of the following
manifestations should the nurse expect?
-Orthostatic hypotension
-Hoarse voice
-Neck vein distention
-Muscle twitching – ANSWER- Orthostatic hypotension
Rationale: The nurse should monitor the client who has a sodium level
of 124 mEq/L for orthostatic hypotension. The expected reference range
for sodium is 136 to 145 mEq/L. Other manifestations of hyponatremia
include decreased deep tendon reflexes, headache, confusion, and
lethargy.
A nurse is admitting a client who has peptic ulcer disease and an upper
gastrointestinal bleed. Which of the following manifestations should the