ATI RN Concept-Based Assessment Level 1 Online Practice A (RNSG1430) San Antonio College

1. A nurse is talking with a client who has major depressive disorder. The client states, "Nobody cares if I'm around or not." Which of the following responses should the nurse take? • It sounds as though you’re feeling hopeless • Rationale: This statement by the nurse is an example of restating, which is a therapeutic response. This technique restates the main idea the client has expressed and allows the client to clarify any misunderstanding. 2. A nurse is preparing to administer a unit of packed RBCs to a client. In adherence with the Joint Commission National Patient Safety Goals regarding blood administration, which of the following actions should the nurse plan to take? • Verify the client and blood component using a two-person process • Rationale: The Joint Commission National Patient Safety Goals regarding blood transfusions includes improving the accuracy of client identification. The nurse should eliminate transfusion errors related to client misidentification by using a two-person verification process to identify the client and the blood component. 3. A nurse on a medical-surgical unit is caring for a group of clients. Which of the following clients should the nurse monitor for the development of reflex urinary incontinence? • A client who has a T12 spinal cord injury • Rationale: The nurse should identify that a client who has a C1 to S2 spinal cord injury is at risk of developing reflex urinary incontinence. With this type of incontinence, the client is unaware that the bladder is full and therefore lacks the urge to void, resulting in the involuntary loss of urine. The nurse should monitor for this form of incontinence and implement interventions such as intermittent catheterization. 4. A nurse is documenting an assessment in a client's electronic health record when an assistive personnel (AP) asks to enter the morning blood glucose for the client. Which of the following actions should the nurse take? • Request that the AP use another computer to enter the data • Rationale: The nurse should request that the AP to go to another computer that is not in use to enter the morning blood glucose from the client. This is time- sensitive data that needs to be entered in the computer as soon as possible. 5. A nurse is preparing to administer acetaminophen 120 mg PO to a toddler. Available is acetaminophen drops 80mg/0.8 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) • 1.2 mL • Rationale: Ratio and Proportion • STEP 1: What is the unit of measurement the nurse should calculate? mL • STEP 2: What is the dose the nurse should administer? Dose to administer = Desired 120 mg • STEP 3: What is the dose available? Dose available = Have 80 mg • STEP 4: Should the nurse convert the units of measurement? No • STEP 5: What is the quantity of the dose available? 0.8 mL • STEP 6: Set up an equation and solve for X. • Have/Quantity = Desired/X • 80 mg/0.8 mL = 120 mg/X mL • X = 1.2 • STEP 7: Round if necessary. • STEP 8: Reassess to determine whether the amount to give makes sense. If there are 80 mg/0.8 mL and the amount prescribed is 120 mg, it makes sense to administer 1.2 mL. The nurse should administer acetaminophen 1.2 mL PO. Desired Over Have • STEP 1: What is the unit of measurement the nurse should calculate? mL • STEP 2: What is the dose the nurse should administer? Dose to administer = Desired 120 mg • STEP 3: What is the dose available? Dose available = Have 80 mg • STEP 4: Should the nurse convert the units of measurement? No • STEP 5: What is the quantity of the dose available? 0.8 mL • STEP 6: Set up an equation and solve for X. • Desired x Quantity/Have = X • 120 mg x 0.8 mL/80 mg = X mL • 1.2 = X • STEP 7: Round if necessary. • STEP 8: Reassess to determine whether the amount to give makes sense. If there are 80 mg/0.8 mL and the amount prescribed is 120 mg, it makes sense to administer 1.2 mL. The nurse should administer acetaminophen 1.2 mL PO. Dimensional Analysis • STEP 1: What is the unit of measurement the nurse should calculate? mL • STEP 2: What is the quantity of the dose available? 0.8 mL • STEP 3: What is the dose available? Dose available = Have 80 mg • STEP 4: What is the dose the nurse should administer? Dose to administer = Desired 120 mg • STEP 5: Should the nurse convert the units of measurement? No • STEP 6: Set up an equation and solve for X. • X = Quantity/Have x Conversion (Have)/Conversion (Desired) x Desired/ • X mL = 0.8 mL/80 mg x 120 mg/ • X = 1.2 • STEP 7: Round if necessary. • STEP 8: Reassess to determine whether the amount to give makes sense. If there are 80 mg/0.8 mL and the amount prescribed is 120 mg, it makes sense to administer 1.2 mL. The nurse should administer acetaminophen 1.2 mL PO 6. A nurse is preparing to administer 0.9% sodium chloride 1,000 mL over 8 hr IV to a client. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) • 125 mL/hr • Rationale: • Follow these steps to calculate the infusion rate: • STEP 1: What is the unit of measurement the nurse should calculate? mL/hr • STEP 2: What is the volume the nurse should infuse? 1,000 mL �...

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