ATI RN
ATI Comprehensive 2023 With NGN 180 Questions And Answers Questions
Extract:
The nurse is continuing to care for the client.
History and Physical
Day 1, 0900:
A 52-year-old client brought to emergency department by adult child. Client is alert and oriented
to person and time but does not know where they are. No history of substance use according to
client's adult child. Client exhibits constant movements and poor concentration. Hair and
clothing are unclean. Appears to be listening to unseen others. Skin turgor poor.
Question 1 of 5
The nurse is providing teaching about lithium to the client and client's adult child. Select the 3 statements the nurse should include.
Correct Answer: B,C,E
Rationale: Blurred vision is not typical; lithium takes time to reach therapeutic levels, causes nausea/drowsiness, and often leads to weight gain. A low-sodium diet is contraindicated due to risk of toxicity.
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.
Question 2 of 5
For each potential intervention, click to specify if the intervention is anticipated or contraindicated for the client.
| Potential Intervention | Anticipated | Contraindicated |
|---|---|---|
| Monitor blood pressure every hour | ||
| Maintain continuous monitoring of the FHR | ||
| Initiate an IV infusion of lactated Ringers | ||
| Place the client in a left lateral position |
Correct Answer: A,B,D
Rationale: Monitoring blood pressure, maintaining continuous FHR monitoring, and placing the client in a left lateral position are all anticipated interventions in labor management.
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 were diagnosed with gestational diabetes at 28 weeks of gestation.
Vital Signs
2000:
Temperature 36.7° C (98.1° F)
Heart rate 98/min
Respiratory rate 20/min
Blood pressure 128/84 mm Hg
Oxygen saturation 98% on room air
Question 3 of 5
Select the 2 findings that require immediate follow-up.
Correct Answer: C,E
Rationale: An elevated fetal heart rate and meconium-stained amniotic fluid indicate potential distress, necessitating urgent intervention.
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 4 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 is collecting a sputum specimen from a client who has tuberculosis.
Question 5 of 5
Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A because it is crucial to obtain the sputum specimen immediately upon the client waking up. This is because sputum produced in the morning is more concentrated and provides a better sample for analysis. Waiting could lead to a diluted sample that may not accurately reflect the client's condition.
Choice B is incorrect as delaying specimen collection could compromise the accuracy of the results.
Choice C is incorrect as it does not specify the optimal timing for specimen collection.
Choice D is incorrect as sterile gloves are not necessary for sputum collection.