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: The correct actions for the nurse to take are A, B, C, D, and E. A: Increasing IV fluid rate helps maintain hydration. B: Notifying the provider is crucial for further medical intervention. C: Placing the client in Trendelenburg position can help prevent cord prolapse. D: Exerting upward pressure on the presenting part can help relieve pressure on the cord. E: Pushing the umbilical cord back can prevent cord compression. F: Administering oxygen, while important, is not specifically mentioned in the scenario.
Extract:
A nurse is caring for a client who is receiving radiation therapy and is experiencing anorexia.
Question 2 of 5
Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Provide the client with cold foods rather than hot foods. This is because cold foods can help reduce oral mucositis, a common side effect of chemotherapy. Hot foods may worsen oral mucositis by irritating the mucous membranes.
Choice B is incorrect as drinking fluids with meals can dilute stomach acid and impair digestion.
Choice C is incorrect as large meals can be difficult to digest for clients undergoing chemotherapy.
Choice D is incorrect as high-protein foods are essential for tissue repair and maintenance during chemotherapy.
Extract:
A nurse is caring for a newborn.
Nurses' Notes
0640:
Weight 4200 gm (9 lb 4 oz), head circumference 35.5 cm (14 in)
Respiratory rate 68/min, with mild grunting.
0650:
Respiratory rate 72/min, with mild grunting
0700:
Respiratory rate 76/min, with moderate grunting and mild intercostal retractions.
Question 3 of 5
The client is at risk for developing------- and----
Correct Answer: B,D
Rationale: Transient tachypnea and hypopycemia are common risks in newborns with respiratory distress.
Extract:
A nurse enters a client's room and sees a small fire in the client's bathroom.
Question 4 of 5
Identify the sequence of steps the nurse should take?
Correct Answer: D
Rationale: The correct answer is D: Activate the facility's fire alarm system. This is the first step the nurse should take in case of a fire emergency to alert everyone in the building and initiate evacuation procedures. By activating the fire alarm system, all occupants including staff and patients will be notified of the fire, allowing for a quicker response from emergency services and a safer evacuation. Closing windows and doors (
A) can help prevent the fire from spreading, but it is not the initial priority. Transporting the client (
B) may put them at risk and should only be done if safe to do so. Using the fire extinguisher (
C) should only be attempted if trained and the fire is small and contained.
Extract:
Question 5 of 5
A nurse is caring for a client whose child died from cancer. The client states 'it's hard to go on without him'. which of the following questions should the nurse ask the client first?
Correct Answer: D
Rationale: The correct answer is D: Are you thinking about ending your life? This question directly addresses the client's statement about finding it hard to go on without their child, revealing any potential suicidal ideation. It is crucial to assess for suicidal thoughts to ensure the client's safety. Asking about past coping strategies (
A) may be helpful but is not as urgent. Inquiring about family history of suicide (
B) can be relevant but is not the priority in this immediate situation. Involving others in care (
C) is important but not as critical as addressing suicidal ideation.