ATI RN
ATI Comprehensive 2023 With NGN 180 Questions And Answers Questions
Extract:
A nurse is caring for a client who is in labor Nurses' Notes
0900:
Contractions occurring every 3 to 4 min, lasting 80 to 90 seconds. Client rates pain with
contractions as 10 on a scale of 0 to 10 and requests an epidural.
Contractions approximately 4 min apart. Vaginal examination reveals cervix dilated 5 cm, 80%
effaced, -1 station, vertex presentation. FHR baseline 142/min with moderate variability. IV fluid
bolus initiated.
0930:
Epidural inserted by anesthesiology. Client reports pain as 2 on a scale of 0 to 10.
0950:
Spontaneous rupture of membranes with clear fluid. 1000:
Variable decelerations noted on the electronic fetal heart rate monitor tracing, FHR baseline
140/min, Deceleration 90/min, tasting 30 seconds: Loop of umbilical cord visible at vaginal
Vital Signs
0900:
Temperature 36.5 C (97.7 F) BP
130/84 mm Hg
Heart rate 108/min
Respiratory rate 18/min
Oxygen saturation 98% on room air
0930:
BP 120/78 mm Hg Heart rate
96/min Respiratory rate
18/min
Oxygen saturation 98% on room air
1000
BP 118/84 mm Hg Heart rate
95/min Respiratory rate
19/min
Oxygen saturation 97% on room air
Question 1 of 5
Select the 5 actions the nurse should take.
Correct Answer: A,B,C,D,E
Rationale:
Correct
Answer: A, B, C, D, E
Rationale:
A: Increasing IV fluid flow rate helps maintain hydration and blood pressure.
B: Notifying the provider ensures timely medical intervention and documentation.
C: Placing the client in Trendelenburg position helps improve placental perfusion.
D: Exerting upward pressure on presenting part can alleviate pressure on the cord.
E: Attempting to push the umbilical cord back can prevent cord compression and fetal distress.
Summary:
F: Administering oxygen may be beneficial but not among the immediate actions required.
G: No information provided about this choice.
Extract:
A nurse is providing an in service about client evacuation during the fracture.
Question 2 of 5
Which of the following clients should the nurse instruct the staff to evacuate first?
Correct Answer: C
Rationale: The correct answer is C: A client who is ambulatory and receiving oxygen. This client should be evacuated first because they are at risk for oxygen-related complications during an emergency. Oxygen supports combustion, increasing the risk of fire. The priority is to remove this client from the area to prevent harm. The other choices are incorrect because: A: Although the client is confused and uses a wheelchair, they are not at immediate risk of harm related to their condition. B: The client who is bedridden and wears a hearing aid is also not at immediate risk of harm. D: The client with a fracture in balance suspension traction can be safely evacuated with assistance and does not have an immediate life-threatening condition.
Extract:
A nurse is caring for a client who is 4 days postpartum following a cesarean birth
Nurses’ Notes
Today
0800
Client reports not feeling well with headache, body aches, and chills. Left breast red and tender
with swollen, tender lymph nodes in the left axilla. Incision edges well approximated without
erythema or drainage. Small amount of Lochia rubra noted.
0830
Provider notified of findings. Prescriptions received.
Question 3 of 5
For each potential assessment finding, click to specify if the assessment finding is consistent with mastitis or endometritis.
| Assessment Findings | Mastitis | Endometritis |
|---|---|---|
| Foul-smelling lochia | ||
| Painful, tender breast | ||
| Temperature | ||
| Chills |
Correct Answer: B,C,D
Rationale:
The correct answer is B, C, D.
B: Painful, tender breast - This finding is consistent with mastitis, which is an infection of the breast tissue.
C: Temperature - This finding is common in both mastitis and endometritis, indicating an infection.
D: Chills - This finding is more indicative of a systemic infection, often seen in endometritis.
Explanation for incorrect choices:
A: Foul-smelling lochia - This finding is more specific to endometritis, not mastitis.
E, F, G: Since these parameters are not provided, they cannot be selected or checked.
Extract:
A nurse is assessing a client who has a possible right pneumothorax.
Question 4 of 5
Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: Reduced right-sided breath sounds. This finding suggests a potential pneumothorax on the right side, where air leaks into the pleural space causing lung collapse and decreased breath sounds. Intercostal retractions (
B) indicate increased work of breathing, likely due to respiratory distress but not specific to a pneumothorax. High-pitched stridor (
C) is a sign of upper airway obstruction, not typically seen with pneumothorax. Paradoxical chest movement (
D) is seen in flail chest, not characteristic of pneumothorax.
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 5 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.