ATI RN
ATI Comprehensive 2023 With NGN 180 Questions And Answers Questions
Extract:
The nurse is continuing to care for the client Nurses
Notes
Day 1, 0900:
Client is at 31 weeks of gestation and presents with a severe headache unrelieved by
acetaminophen. Client also reports urinary frequency and decreased fetal movement.
Client is a G3 P2 with one preterm birth.
Day 1, 0930:
Client reports a constant and throbbing headache and rates it as a 6 on a scale of 0 to 10. Denies
visual disturbances. +3 pitting edema in bilateral lower extremities. Patellar reflex 4+ without
the presence of clonus. Client reports occasional nighttime leg cramps. Reports three fetal
movements within the last 30 min, External fetal monitor applied with a baseline FHR 140/min
with occasional accelerations and moderate variability. No uterine contractions noted.
Question 1 of 5
The nurse is reviewing the assessment findings. For each assessment finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.
| Assessment Findings | Preeclampsia | HELLP syndrome |
|---|---|---|
| Hemoglobin | ||
| Alanine aminotransferase (ALT) | ||
| Blood pressure | ||
| Platelet count |
Correct Answer: C,D
Rationale: [
Rationale:
- Blood pressure is a key assessment finding for both preeclampsia and HELLP syndrome. In preeclampsia, hypertension is a hallmark feature, while in HELLP syndrome, it can also be elevated.
- Platelet count is another shared finding. Thrombocytopenia is a common feature of HELLP syndrome, while it can also be decreased in severe cases of preeclampsia.
- Hemoglobin and ALT levels are not specific to either condition, so they do not provide a clear indication of preeclampsia or HELLP syndrome.]
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
The nurse should first notify the provider about------- followed by the-----------
Correct Answer: C
Rationale: The green color of amniotic fluid indicates meconium-stained fluid which can be a sign of fetal distress.
Extract:
A nurse is caring for a client who has respiratory depression from an opioid administration.
Question 3 of 5
After administering naloxone, which finding should the nurse expect?
Correct Answer: B
Rationale: Naloxone reverses opioid effects, leading to increased respiratory rate.
Extract:
A nurse is assessing a client who has type one diabetes myelitis and was administered insulin lispro 1 hour ago.
Question 4 of 5
Which of the following manifestations indicates that the client might be experiencing hypoglycemia?
Correct Answer: A
Rationale: The correct answer is A: Confusion. Hypoglycemia is characterized by low blood sugar levels, leading to neuroglycopenic symptoms like confusion. Increased thirst (
B) and frequent urination (
C) are more indicative of hyperglycemia. Flushed skin (
D) is not typically associated with hypoglycemia.
Extract:
A nurse manager is updating protocols for the use of belt restraints.
Question 5 of 5
Which of the following guidelines should the nurse include?
Correct Answer: A
Rationale: The correct answer is A: Document the client's condition every 15 minutes. This guideline is crucial to ensure the client's safety and well-being when using restraints. Documenting the client's condition regularly allows the nurse to monitor for any changes or signs of distress promptly. This frequent monitoring helps prevent complications or harm that may arise from the use of restraints.
Explanation for why the other choices are incorrect:
B: Attaching the restraint straps to the side rails of the bed can be dangerous as it may cause entrapment or injury to the client.
C: Using a square knot to secure the restraint is not recommended as it can be difficult to untie quickly in case of an emergency.
D: Ensuring there is at least a 2-inch gap between the restraint and the client's body is incorrect because restraints should be applied securely to prevent the client from slipping out or causing self-harm.