ATI RN
ATI Comprehensive 2023 With NGN 180 Questions And Answers Questions
Extract:
A nurse is caring for a 9-year-old child at a clinic.
Nurses' Notes
1000:
Child has been brought to the clinic by their parent due to a report of right arm pain. The parent
states that several hours ago the child tripped and fell onto the sidewalk while playing
outside. The child states, "I was running when we were playing. and I tripped over a curb." Child
is supporting their arm across their body.
Assessment
Respirations easy and unlabored, Abdomen non-distended. Right forearm and fingers are
edematous. Ecchymotic area noted on outer aspect of the forearm. Radial pulse +2. Fingers
slightly cool to touch. Child can move fingers and reports a mild "tingling" sensation, Child
verbalizes a pain level of 4 on a scale of 0 to 10, Multiple areas of bruising are noted on lower
extremities in various stages of healing
Vital. Signs
Temperature 36.8°C (98.2° F)
Heart rate 102/min
Respiratory rate 22/min
BP 100/60 mm Hg
Oxygen saturation 98% on room air
Question 1 of 5
Nurse reviews the assessment findings. Which findings require immediate follow-up?
Correct Answer: A,D
Rationale: Edema and coolness in the extremity suggest circulatory impairment, warranting immediate attention.
Extract:
A nurse is planning care for a client who was receiving continuous internal tube feeding through an open system.
Question 2 of 5
Which intervention should the nurse include in the plan of care?
Correct Answer: E
Rationale: The correct answer is E, replacing the feeding container and tubing every 24 hours. This is essential to prevent bacterial growth and reduce the risk of infection. Placing a formula in the container for 18 hours (
A) may lead to contamination. Flushing the feeding tube with water every 4 to 6 hours (
B) is important but not the priority compared to changing the container. Covering and labeling the container (
C) is good practice but does not address the need for regular replacement. Elevating the head of the bed during feeding (
D) is important for preventing aspiration but not directly related to the equipment hygiene.
Extract:
A nurse is caring for a client who has a stool culture that is positive for Clostridium difficile.
Question 3 of 5
Which of the following infection control precautions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B because placing the client in a private room with contact precautions helps prevent the spread of infection to others. This measure includes using personal protective equipment (PPE) and limiting contact with others to contain potential infectious agents. Removing the protective gown in the client's room (
A) is incorrect as it exposes the nurse to potential contamination. Performing hand hygiene with an alcohol-based sanitizer (
C) is important but does not address the isolation of the client. Wearing an N95 mask (
D) is specific to airborne precautions, not contact precautions.
Extract:
A nurse is preparing to initiate intravenous fluids via pump for a client.
Question 4 of 5
which of the following actions should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Ensure the IV tubing is primed and free of air bubbles before connecting it to the client. Priming removes air, preventing air embolism. Air bubbles can lead to complications. Option A is incorrect as surge protectors are not relevant to IV pump use. Option C is incorrect as the pump should be above heart level to prevent rapid infusion. Option D is incorrect as catheter gauge selection depends on patient needs, not a fixed number.
Extract:
A nurse is caring for a child who has cystic fibrosis and requires posterior drainage.
Question 5 of 5
Which action should the nurse take?
Correct Answer: A
Rationale: The correct action for the nurse to take is choice A: Perform the procedure prior to meals. This is because performing procedures prior to meals helps prevent aspiration during feeding. The rationale behind this is that when the stomach is empty, there is reduced risk of regurgitation and aspiration of food particles during the procedure.
Choices B, C, and D are incorrect. Performing chest physiotherapy immediately after feeding can increase the risk of regurgitation and aspiration. Placing the child in a supine position during the procedure can also increase the risk of aspiration. Limiting fluid intake before the procedure is not necessary and may lead to dehydration, which is not recommended.