ATI RN
ATI Comprehensive 2023 With NGN 180 Questions And Answers Questions
Extract:
A nurse is reading a tuberculin skin test for a client who received a protein derivative test 72 hours ago.
Question 1 of 5
Which of the following findings indicate a positive test?
Correct Answer: A
Rationale: The correct answer is A because an induration measuring 10 mm is considered positive for a tuberculin skin test, indicating exposure to tuberculosis. A larger induration size suggests a stronger immune response.
Choice B, a reddened area with no induration, is not specific for a positive test.
Choice C, an induration measuring 3 mm, is below the threshold for positivity.
Choice D, a blister at the injection site, is a sign of irritation rather than a positive test result.
Extract:
A nurse is caring for a client who was at 33 weeks of gestation following an amniocentesis.
Question 2 of 5
Which complication should the nurse monitor for?
Correct Answer: A
Rationale: The correct answer is A: Contractions. Nurses should monitor for contractions as they could indicate preterm labor or other complications. Increased fetal movement (
B) is not necessarily a complication but could be a sign of fetal well-being. Hypertension (
C) is important to monitor but may not be directly related to the current situation. Hypoglycemia (
D) is also important but not typically a primary concern in this situation.
Extract:
A nurse is planning care for a client who was recently admitted to the
medical-surgical unit.
Diagnostic Results
Day 1:
WBC count 4,500/mm³ (5,000 to 10,000/mm³)
RBC count 3.2 million/mm³ (4.2 to 5.4 million/mm³)
Hgb 11 g/di (12 to 16 g/dL)
Hct 46% (37% to 47%) '
Platelet count 145,000/mm³ (150,000 to 400,000/mm³)
Erythrocyte sedimentation rate 40 mm/hr (up to 20 mm/hr)
Urinalysis:
pH 5.0 (4.6 to 8.0)
Specific gravity 1.0 (1.010 to 1.025)
Protein 10 mg/dL (0 to 8 mg/dL)
Glucose negative (Negative)
WBC casts 2 (0 to 4 per low-power field)
Admission Assessment
Client reports new onset of fever and discomfort in their joints and increase malaise. No relevant
medical history. Client is alert to person, place, time, and situation. Reports generalized pain as 4
on a scale of 0 to 10. Macular rash present on cheeks bilateral. Lungs clear anterior and posterior.
Bowel sounds active in all 4 quadrants. Last bowel movement 1 day ago. Skin warm, dry, and
intact. Capillary refill less than 3 seconds. A 20-gauge IV saline lock inserted in back left hand
Question 3 of 5
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing.
Action to Take
Potential Condition
Parameter to Monitor
Correct Answer: B,E
Rationale: Systemic lupus erythematosus is indicated by the lab results and symptoms.
Extract:
A nurse is caring for a client in the emergency department. Nurses' Notes
1100:
The client reports shortness of breath and difficulty sleeping. The client feels tired very quickly
and occasionally feels nauseous. The client reports experiencing intermittent chest tightness and
a cough that is aggravated by exercise. The client has a productive cough and irregular breathing
pattern. Crackles and wheezing present on auscultation. The client has a history of smoking a
pack of cigarettes per day for the past 35 years. There is no clubbing of the fingers. The client
appears anxious.
1130:
Administered albuterol and oxygen per provider's prescription. The client is instructed to perform
pursed-lip breathing.
1230:
The client is breathing with minimal effort and coughing has decreased
Vital Signs 1100:
Temperature 36.8°C (98.2° F) Heart
rate 92/min Respiratory rate 28/min
BP 145/90 mm Hg
Oxygen saturation 87% on room air
1145:
Temperature 36.2° C (97.2" F) Heart
rate 88/min
Respiratory rate 22/min BP
140/90 mm Hg
Oxygen saturation 92% on room air
Question 4 of 5
Which of the following interventions should the nurse include in the plan of care? Select all that apply.
Correct Answer: A,B,F
Rationale: The correct interventions are A, B, and F.
A: Increasing oxygen flow rate to 4 L/min ensures adequate oxygenation for the client.
B: Assessing breath sounds helps monitor respiratory status and detect any abnormalities.
F: Instructing the client to perform diaphragmatic breathing promotes effective use of respiratory muscles.
Incorrect choices:
C: Chest percussion and vibration are not typically indicated for all clients and may not be appropriate in this case.
D: Placing the client in a supine position can worsen respiratory function, especially in certain conditions.
E: Restricting fluid intake may not be necessary unless specifically ordered by a healthcare provider and could potentially lead to dehydration.
Extract:
A nurse in an acute care mental health facility is placing a client in seclusion and restraints.
Question 5 of 5
Which of the following actions should the nurse plan to take?
Correct Answer: C
Rationale: The correct answer is C: Release the restraints every 2 hours to assess circulation. This action is essential to prevent complications related to impaired circulation and tissue damage. Releasing the restraints allows the nurse to assess the client's circulation, skin integrity, and comfort. It promotes safety and prevents potential harm.
Choice A (Document the client's behavior every 15 minutes) is not the best action as it focuses on behavior rather than safety and circulation.
Choice B (Obtain a prescription for restraints within 4 hours) is not necessary as restraints should only be used if all other options have been exhausted.
Choice D (Discontinue restraints only when the provider removes the order) is incorrect as the nurse should assess the client's condition independently and not solely rely on provider orders.