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:
A nurse in an outpatient clinic is caring for a client.
Assessment
0840:
Client is calm and cooperative. Skin warm and dry. No rash noted. Lung sounds clear. Abdomen
soft to palpation with fundal height at 20 cm. Fetal heart rate 150/min. Bowel sounds active in all
four quadrants. No edema to lower extremities. Client denies visual changes or severe headaches.
Weight gain of 1.8 kg (4 lb) since last visit. Small amount of mucoid discharge noted on perineal
pad
Laboratory Results
0900:
Urine dipstick:
pH 6.0 mg/d (4.6 to 8 mg/dL)
Specific Gravity 1.022 (1.010 to 1.025)
Leukocyte esterase negative (Negative)
Nitrite negative (Negative)
Protein trace negative (Negative)
Glucose negative (Negative)
Ketones none (None)
Bilirubin none (None)
Blood none (None)
Nurses' Notes
0830:
Client reports to clinic for monthly prenatal visit. Client is at 20 weeks of gestation. Since last
visit, client reports concerns about the occurrence of intermittent mild backaches, increased
heartburn, generalized itching, and vaginal discharge.
Vital Signs
0830:
BP 124/68 mm Hg
Heart rate 80/min
Temperature 37° C (98.6° F)
Respiratory rate 16/min
Weight 67.1 kg (148 lb)
Question 2 of 5
Which of the following statements should the nurse include in the client's teaching?
Correct Answer: B,D,F
Rationale: Wearing flat shoes, wearing loose-fitting clothes, and avoiding fried foods are beneficial practices during pregnancy.
Extract:
A nurse is caring for a 75-year-old client who is admitted to the medical-surgical unit
Nurses' Notes
Today
0700:
Received change of shift report. Client is 2 days postoperative following a hysterectomy and
they have not yet ambulated with physical therapy due to significant postoperative pain. Per
change of shift report, pain medications have been adjusted and pain has improved. Client
currently reports pain level as 2 on a scale of 0 to 10.
0900:
Ambulating in hallway with the assistance of physical therapy.
1000:
Return to bed with siderails up x 2, but not wearing sequential compression devices because they
"hurt too much." Applied antiembolism stockings.
1400:
Client notified nurse that right leg is warm and painful. Assessment reveals unilateral right lower
extremity swelling and warmth below the knee. Provider notified.
Laboratory Results
Today
1430:
WBC count 10,500/mm³ (5,000 to 10,000/mm³)
Hgb 11.1 g/dL (12 to 16 g/dL)
Hct 34% (37% to 47%6)
Platelet count 250,000/mm³ (150,000 to 400,000/mm³)
Coagulation studies:
PT 11.5 seconds (11 to 12.5 seconds)
INR 0.9 (0.8 to 1.1)
History and Physical
3 days ago:
Past medical history: Type 2 diabetes mellitus, hypertension
Surgical history: Cesarean birth x 2 as a young adult
Social history: Has smoked 1 pack of cigarettes per day for 4 years, drinks socially, does not
exercise.
Weight: 121,3 kg (267.4 lb)
Vital Signs
Today
0800
Temperature 37° C (98.6" F)
Heart rate 97/min
Respiratory rate 18/min
BP 138/78 mm Hg
Question 3 of 5
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing.
Action to Take
Potential Condition
Parameter to Monitor
Correct Answer: C
Rationale: Unilateral swelling and warmth suggest deep vein thrombosis (DVT), requiring assessment for ischemia.
Extract:
A home care nurse is caring for a client who has advancing multiple sclerosis.
Nurses' Notes
2 weeks ago:
Client reports depression is increasing as they are unable to participate in activities they once
enjoyed because of the advancing multiple sclerosis. Even getting up to the wheelchair is "just
too much" for them.
Today:
Home health aide reported client will not permit turning or position changes. Client states, "I can
only get comfortable curled on my left side, I'm not moving."
Question 4 of 5
Select the 5 complications the client is at risk for.
Correct Answer: C,D,E,F,H
Rationale: Immobility increases risks of urinary stasis, contractures, atelectasis, and pressure injuries.
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 5 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.