ATI Comprehensive 2023 With NGN 180 Questions And Answers | Nurselytic

Questions 160

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ATI Comprehensive 2023 With NGN 180 Questions And Answers Questions

Extract:

A nurse is caring for a child who has cystic fibrosis and requires posterior drainage.


Question 1 of 5

Which action should the nurse take?

Correct Answer: A

Rationale: The correct action for the nurse to take is choice A: Perform the procedure prior to meals. This is because performing procedures prior to meals helps prevent aspiration during feeding. The rationale behind this is that when the stomach is empty, there is reduced risk of regurgitation and aspiration of food particles during the procedure.

Choices B, C, and D are incorrect. Performing chest physiotherapy immediately after feeding can increase the risk of regurgitation and aspiration. Placing the child in a supine position during the procedure can also increase the risk of aspiration. Limiting fluid intake before the procedure is not necessary and may lead to dehydration, which is not recommended.

Extract:

A nurse is caring for a client who has heart failure.


Question 2 of 5

Which of the following manifestations should the nurse expect?

Correct Answer: A

Rationale: The correct answer is A: Crackles in the lungs. This manifestation is expected because crackles indicate fluid accumulation in the lungs, which is common in conditions like heart failure. Bradycardia (
B) is unlikely as heart failure often causes tachycardia. Dry mucous membranes (
C) are more indicative of dehydration. Weight loss (
D) is not a typical manifestation of heart failure. Hence, crackles in the lungs are the most relevant manifestation.

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 3 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 client who is pregnant. 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.
Vital Signs Day
1, 0900:
Temperature (oral) 36.9°C (98,4° F) Heart
rate 72/min
Respiratory rate 16/min BP
162/112 mm Hg
Oxygen saturation 97% on room air
Diagnostic Results Day 1,
1000:
Appearance cloudy (clear) Color
yellow (yellow)
pH 5.9 (4.6 to 8)
Protein 3+ (negative)
Specific gravity 1.013 (1.005 to 1.03) Leukocyte esterase
negative (negative)
Nitrites negative (negative) Ketones
negative (negative) Crystals negative
(negative) Casts negative (negative)
Glucose trace (negative) WBC 5 (0
t0 4)
WBC casts none (none)
RBC 1 (less than or equal to 2) RBC
casts none (none)


Question 4 of 5

The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.

Correct Answer: A,C,F,G

Rationale: The correct answers are A, C, F, and G. A high urine protein level indicates possible preeclampsia, a serious prenatal complication. Elevated blood pressure is also a sign of preeclampsia. Headaches can be a symptom of hypertension or preeclampsia. Gravida/parity helps assess the client's obstetric history, which can indicate potential complications. Fetal activity, urine ketones, and respiratory rate are not direct indicators of prenatal complications.

Extract:

A nurse is planning care for a client who is to receive alteplase recombinant for a thrombus in the coronary artery.


Question 5 of 5

Which of the following actions should the nurse include in the plan of care?

Correct Answer: A

Rationale: The correct answer is A: Observe for bruising of the skin. This is important in assessing for signs of potential bleeding, which could indicate a complication. Monitoring for bruising can help detect early signs of internal bleeding, especially in patients at risk due to certain medical conditions or medication use. Providing a diet low in protein (
B) is not relevant to the question and could potentially harm the patient's nutritional status. Monitoring vital signs every hour for the first 4 hours (
C) may not be necessary unless there are specific indications for frequent monitoring. Administering medications intramuscularly (
D) is not directly related to observing for bruising and may not be the priority in this situation.

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