ATI RN
ATI Comprehensive 2023 With NGN 180 Questions And Answers Questions
Extract:
A nurse in an acute care mental health facility is placing a client in seclusion and restraints.
Question 1 of 5
Which of the following actions should the nurse plan to take?
Correct Answer: C
Rationale: The correct answer is C: Release the restraints every 2 hours to assess circulation. This action is essential to prevent complications related to impaired circulation and tissue damage. Releasing the restraints allows the nurse to assess the client's circulation, skin integrity, and comfort. It promotes safety and prevents potential harm.
Choice A (Document the client's behavior every 15 minutes) is not the best action as it focuses on behavior rather than safety and circulation.
Choice B (Obtain a prescription for restraints within 4 hours) is not necessary as restraints should only be used if all other options have been exhausted.
Choice D (Discontinue restraints only when the provider removes the order) is incorrect as the nurse should assess the client's condition independently and not solely rely on provider orders.
Extract:
A nurse is reviewing the medical records of four clients.
Question 2 of 5
The nurse should identify that which of the following client findings requires follow-up care?
Correct Answer: C
Rationale: The correct answer is C. A client taking warfarin with an INR of 1.8 requires follow-up care because it indicates insufficient anticoagulation, putting the client at risk for clot formation. An INR of 1.8 is below the therapeutic range (usually 2-3 for most indications) for warfarin therapy. This can lead to inadequate prevention of blood clots, increasing the risk of thromboembolic events. Follow-up care may involve adjusting the warfarin dosage to achieve the target INR range.
Choice A is incorrect because an induration after a Mantoux test is an expected finding and does not necessarily require follow-up care.
Choice B is incorrect as taking sodium phosphate before a colonoscopy is a standard preparation and does not indicate a need for immediate follow-up care.
Choice D is incorrect as a potassium level of 3.6 mEq/L is within the normal range (3.5-5.0 mEq/L
Extract:
A nurse is assessing a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate 4 hours ago. The nurse notes pink tinged urine and the drainage bag.
Question 3 of 5
Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Maintain the irrigation solution rate. This is the appropriate action because maintaining the irrigation solution rate ensures continuous flushing of the catheter to prevent blockages and maintain patency. Increasing the rate could lead to complications like fluid overload. Clamping the catheter and reassessing can cause catheter obstruction. Notifying the provider immediately may not be necessary unless there are specific complications or concerns.
Extract:
The charge nurse on a medical surgical unit is assisting with the emergency response plan following an external disaster in the community.
Question 4 of 5
In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?
Correct Answer: A
Rationale: The correct answer is A. The client one day postoperative following a vertebroplasty can be recommended for early discharge as this procedure is typically short-stay and does not require extended monitoring. The client is likely stable and can continue recovery at home.
Choice B is incorrect because a client with pneumonia and a fever of 101°F requires continued IV antibiotics and monitoring to ensure resolution of infection and fever reduction.
Choice C is incorrect as a client with a recent TIA requires further evaluation and monitoring to prevent recurrent strokes and assess for potential complications.
Choice D is incorrect because a client with uncontrolled atrial fibrillation requiring continuous cardiac monitoring should not be discharged early as they need close monitoring and management to prevent complications like stroke or heart failure.
Extract:
A nurse is caring for a client who has pneumonia and tells the nurse, “I feel like an elephant is sitting on my chest.†The client is weak and unable to walk.
Question 5 of 5
After the nurse indicates chest pain protocol, which of the following is the priority diagnostic test?
Correct Answer: C
Rationale: The correct answer is C: Chest X-ray. When a patient presents with chest pain, a chest X-ray is crucial to evaluate for any acute cardiopulmonary conditions like pneumonia, pneumothorax, or aortic dissection. It helps identify any immediate life-threatening issues that require prompt intervention. PT and INR (
A) are coagulation tests not typically indicated for acute chest pain. A 12-lead ECG (
B) is important but usually done after the chest X-ray to assess for cardiac abnormalities. D-dimer test (
D) is used to rule out pulmonary embolism, but it is not the priority test in the initial evaluation of chest pain.