ATI RN
ATI Comprehensive 2023 With NGN 180 Questions And Answers Questions
Extract:
A nurse in an antepartum unit is caring for a client.
Nurses' Notes
2000:
Client is 38-year-old, G4 P3 at 38 weeks of gestation. Presents for evaluation of labor and
spontaneous rupture of membranes (SROM). Client states, "My water broke a couple of hours
ago and is a greenish color," Client also reports contractions began about 4 hr. ago and have
become consistently stronger and closer together.
Electronic fetal monitor applied. Small amount of thin green fluid noted on perineal pad.
Contraction palpated, lasted 40 seconds, moderate in intensity. Fetal heart rate (FHR) 165/min.
Vaginal examination performed: cervix 4 cm dilated, 70% effaced, 0 station, vertex presentation.
Client reports a history of chronic hypertension that has been well-controlled during this
pregnancy. Also states was diagnosed with gestational diabetes at 28 weeks of gestation.
2020:
Contractions occurring every 4 to 5 min, lasting 40 to 60 seconds. Small amount of bloody show
noted when changing disposable pad on bed. Client rates contraction pain as a 5 on a scale of 0
to 10, breathing well through contractions., FHR 168/min, minimal variability. Client denies
epigastric pain or visual disturbances. Trace of edema noted to bilateral lower extremities.
Question 1 of 5
For each potential intervention, click to specify if the intervention is anticipated or contraindicated for the client.
| Potential Intervention | Anticipated | Contraindicated |
|---|---|---|
| Monitor blood pressure every hour | ||
| Maintain continuous monitoring of the FHR | ||
| Initiate an IV infusion of lactated Ringers | ||
| Place the client in a left lateral position |
Correct Answer: A,B,D
Rationale: Monitoring blood pressure, maintaining continuous FHR monitoring, and placing the client in a left lateral position are all anticipated interventions in labor management.
Extract:
A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother.
Question 2 of 5
Which of the following responses should the nurse make?
Correct Answer: A
Rationale: The correct answer is A because it acknowledges the caregiver's potential need for support and offers information on respite care, showing empathy and understanding.
Choice B is incorrect as it overlooks the caregiver's own needs and can come off as dismissive.
Choice C may be true for some individuals, but it doesn't address the caregiver's current struggles.
Choice D places undue pressure on the caregiver to suppress their own emotions.
Extract:
A nurse is caring for a client.
Laboratory Results
Week 1:
WBC count 8,000/mm³ (5,000 to 10,000/mm³)
Platelets 350,000/mm³ (150,000 to 400,000/mm³)
Potassium 3.7 mEq/L (3.5 to 5 mEq/L)
Week 2:
WBC count 3,800/mm³ (5,000 to 10,000/mm³)
Platelets 150,000/mm³ (150,000 to 400,000/mm³)
Potassium 3.6 mEq/L (3.5 to 5 mEq/L)
Vital Signs
Week 2:
Temperature 38.6° C (101.5° F)
BP 114/56 mm Hg
Heart rate 102/min
Respiratory rate 24/min
Oxygen saturation 93% on room air
Question 3 of 5
A nurse is reviewing the client's electronic medical record. Which of the following findings require follow up?
Correct Answer: C,D
Rationale: Decreased WBC count and elevated temperature suggest infection, requiring follow-up. Potassium levels remain within normal range, so no action is needed.
Extract:
A nurse is assessing a child who has bacterial pneumonia.
Question 4 of 5
Which of the following manifestations should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: Fever. In response to infection, the body releases pyrogens that reset the hypothalamic thermostat leading to fever. This is a common manifestation indicating an immune response. Bradycardia (
B) is unlikely in an infection as the body usually increases heart rate to pump more blood. Dry skin (
C) is not directly related to infection but may occur due to dehydration. Decreased respiratory rate (
D) is uncommon in infections as the body usually increases respiratory rate to meet oxygen demands.
Extract:
A nurse is providing preoperative teaching to a client about the administration of morphine via a PCA pump.
Question 5 of 5
Which of the following statements by the client indicates an understanding of the teaching?
Correct Answer: A
Rationale: The correct answer is A because it demonstrates the client's comprehension of the concept of patient-controlled analgesia (PC
A). By stating "I will receive a limited amount of pain medication when I press the button," the client shows an understanding that the PCA pump delivers a set dose of medication upon activation. This indicates awareness of the mechanism and purpose of the PCA pump.
Choice B is incorrect as it suggests having someone else press the button, which goes against the principle of patient-controlled administration.
Choice C is incorrect because it implies unlimited access to medication, which could lead to overdose.
Choice D is incorrect as it suggests waiting for severe pain, which may compromise effective pain management.