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.
2230:
Contractions occurring every 2.5 to 3 minutes, lasting 60 to 70 seconds. Epidural placed by
anesthesiologist. Client rates pain with contractions as a 3 on a scale of 0 to 10. FHR 150/min
with moderate variability. Accelerations present, no decelerations noted.
Vital Signs
2230:
Temperature 38° C (100.4° F)
Heart rate 88/min
Respiratory rate 16/min
Blood pressure 122/80 mm Hg
Oxygen saturation 98% on room air
Question 1 of 5
Select the findings that indicate the interventions have been effective.
Correct Answer: A,C
Rationale: Effective pain relief (client rates pain as 3) and normal FHR patterns indicate successful interventions.
Extract:
History and Physical
6-year-old child
Vomited 3 times in the past 24 hr
Irritable behavior for the past 24 hr
Respiratory infection started 3 days ago
Brudzinski's and Kernig's signs positive
Question 2 of 5
Nurse is planning care for a child during admission to the facility. Which action should the nurse take first?
Correct Answer: D
Rationale: Positive Brudzinski's and Kernig's signs indicate meningitis, making seizure precautions the priority to prevent complications.
Extract:
A nurse is teaching about preventative measures to a female client who has chronic urinary tract infections.
Question 3 of 5
Which of the following interventions should the nurse include in the teaching?
Correct Answer: C
Rationale: The correct answer is C: Urinate immediately after sexual intercourse. This intervention helps prevent urinary tract infections by flushing out bacteria that may have entered the urethra during intercourse. Drinking warm water (
A) is not necessary in this context. Wiping back to front (
B) can introduce bacteria into the urinary tract. Limiting fluid intake (
D) is not recommended as it can concentrate urine and increase the risk of UTIs.
Extract:
A school nurse is performing scoliosis screening.
Question 4 of 5
The nurse should recognize which of the following clinical manifestations as an indication of scoliosis?
Correct Answer: A
Rationale: The correct answer is A: Uneven shoulder and pelvic heights. Scoliosis is characterized by a lateral curvature of the spine, leading to uneven shoulder and pelvic heights. This is a classic clinical manifestation of scoliosis, as the spine's abnormal curvature causes the body to tilt to one side, resulting in the uneven alignment of the shoulders and pelvis. Symmetrical scapulae (
B), equal leg lengths (
C), and straight spinal alignment (
D) are not indicative of scoliosis, as scoliosis specifically involves a lateral, often S-shaped, curvature of the spine.
Extract:
Question 5 of 5
A nurse is Inserting an indwelling urinary catheter to a male client. Which of the following actions should the nurse take?
Correct Answer: D
Rationale:
Correct Answer: D - Lift the penis so that it is perpendicular to the client's body
Rationale: Lifting the penis perpendicular to the client's body helps to straighten the urethra, making it easier to insert the catheter. This position minimizes the risk of causing trauma or discomfort to the client during the insertion process. It also allows for better visualization and manipulation of the urinary meatus, ensuring proper placement of the catheter.
Summary of Other
Choices:
A: Cleansing the tip of the penis in a side to side motion is incorrect as it does not directly relate to the insertion technique of the catheter.
B: Picking up the catheter 13 cm (5 in) from its tip is incorrect as it does not address the proper positioning of the penis during insertion.
C: Performing the cleansing procedure with a fresh swab two times is incorrect as it focuses on the cleansing process rather than the insertion technique.