ATI RN
ATI Comprehensive 2023 With NGN 180 Questions And Answers Questions
Extract:
The nurse is continuing to care for the client.
Provider Prescriptions Day 1,
1030
Admit to obstetrical unit.
Serum magnesium level per facility policy 24 hr urine
for total protein and creatinine Insert indwelling
urinary catheter Continuous external fetal monitoring
Administer loading dose of magnesium sulfate 4 g via Intermittent IV bolus over 20 min
followed by a maintenance dose of 2 g/hr
Lactated Ringer's 50 ml/tr via continuous iV infusion Betamethasone
12 mg IM X2 doses given 24 hr apart
Labetalol 20 mg IV bolus now, then 100 mg PO twice dally starting at 2000 Vital signs every 30
min
Acetaminophen 650 mg PO every 6 hr PRN pain Hourly intake and
output
Question 1 of 5
The provider has admitted the client to the inpatient obstetrics unit and written prescriptions based on the client's condition. The action the nurse should take first is------followed by ----------
Correct Answer: C,D
Rationale: First, checking the client's blood pressure (
C) is crucial to assess the client's immediate condition and determine if there are any signs of hypertensive crisis that require immediate intervention. Administering labetalol (
D) is the next step if the blood pressure is elevated, as this medication helps lower blood pressure in cases of preeclampsia or hypertension, which could pose a risk to both the client and the fetus. Evaluating the fetal heart rate (
A) is important but can be done after stabilizing the client's blood pressure. Monitoring urine output (
B) is important for assessing renal function but is not as urgent as addressing blood pressure. Starting continuous IV infusion (E) and inserting a urinary catheter (F) may be necessary later but are not the immediate priority in this situation.
Extract:
A nurse is caring for a client in active labor.
Admission Assessment
0200:
Gravida 1, Para 0 at 39 weeks gestation. Presents with contractions occurring every 5 to 6 min,
45 to 60 seconds duration. Cervical examination 4 cm dilated, 50% effaced. Admit to labor and
delivery unit.
Nurses' Notes
0200:
Admitted to labor and delivery unit, reports pain as 7 on a scale of 0 to 10 with contractions.
Cervix 4 cm dilated, 50% effaced, with membranes intact.
0230:
Client reports increasing discomfort with contractions. Cervix 5 cm dilated, 60% effaced, with
membranes intact. Contractions occurring every 5 min, 45 to 60 seconds duration.
0300:
Epidural anesthesia initiated, Cervix 7 cm dilated, 70% effaced, with membranes intact.
Contractions occurring every 4 to 5 min. 60 seconds duration,
Vital Signs
0200:
Temperature 36.9° C (98.4° F)
Heart rate 86/min
Respiratory rate 18/min
BP 118/78 mm Hg
0230:
Temperature 37° C (98.6° F)
Heart rate 88/min
Respiratory rate 20/min
BP 120/80 mm Hg
0300:
Temperature 37.1°C?98.8°F?
Heart rate 90/min
Respiratory rate 18/min
BP 122/76 mm Hg
The nurse is assuming care for the client at 0305.
Question 2 of 5
For each nursing action, click to specify if the nursing action is essential or contraindicated for the client.
| Nursing Action | Essential | Contraindicated |
|---|---|---|
| Assist the client with ambulation | ||
| Inform the client to expect drowsiness | ||
| Monitor for elevated temperature | ||
| Assess for urinary retention | ||
| Encourage the client to turn from side to side |
Correct Answer: C,D,E
Rationale: Monitoring temperature, assessing urinary retention, and encouraging position changes are essential after epidural administration.
Extract:
A nurse is caring for a 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.
Nurses Notes
Day 1. 0915
The client's adult child reports the client has not slept for 2 days and has become obsessed with
cleaning the house and hosting parties. At times the client is overly joyous and has a very
elevated sense of self-confidence. The adult child states that the client has also demonstrated
very impulsive spending habits and expresses concern about the client giving away large sums
of money to others
The client's speech is very pressured, disorganized, and loud. Client unable to recall the last time
they ate
Vital Signs
Day 1, 0905:
Temperature 37.1° C (98,8° F)
Heart rate 120/min
Respiratory rate 19/min
BP 138/88 mm Hg
Oxygen saturation 98% on room air
Question 3 of 5
Select the 4 findings that require immediate follow up
Correct Answer: A,B,C,D
Rationale: These findings indicate potential medical emergencies. Hallucinations suggest psychosis, elevated heart rate could indicate mania or other conditions, disrupted sleep patterns may signify mania or delirium, and poor skin turgor points to dehydration.
Extract:
A nurse in a long-term care facility is admitting a client with dementia.
Question 4 of 5
Which of the following actions should the nurse take to reduce the risk for client injury?
Correct Answer: C
Rationale: The correct answer is C: Raise the side rails up when the client is in bed. This action helps prevent the client from falling out of bed, reducing the risk for injury. Side rails provide physical barriers to keep the client safe while sleeping or resting. Keeping the television on during the night (
A) does not directly address the risk for client injury. Placing the bedside table at the foot of the bed (
B) is not as effective in preventing falls as raising the side rails. Assisting the client to the toilet frequently (
D) is important but does not specifically address the risk for client injury while in bed.
Extract:
A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion.
Question 5 of 5
Which of the following actions should the nurse plan to take?
Correct Answer: C
Rationale: The correct action is to protect the IV bag from exposure to light (
Choice
C) to prevent photochemical degradation of the medication inside, which can reduce its effectiveness or cause potential harm to the patient. Keeping calcium gluconate at the client's bedside (
Choice
A) is not necessary unless specifically indicated. Monitoring blood pressure every 2 hours (
Choice
B) is important but not directly related to IV bag exposure to light. Attaching an inline filter to the IV tubing (
Choice
D) is a good practice to prevent particulate matter from entering the patient's bloodstream but is not the most critical action in this scenario.