ATI RN
ATI Comprehensive 2023 With NGN 180 Questions And Answers Questions
Extract:
A nurse is conducting an initial assessment of a client and notices a discrepancy Between the clients current IV infusion and the information received during the shift's report.
Question 1 of 5
Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A. The nurse should compare the current infusion with the prescription and the client's medical record to ensure accuracy and safety. This step is crucial in preventing medication errors and ensuring that the right medication is given to the right patient at the right time. Adjusting the IV infusion rate without verifying the information can lead to potential harm (choice
B). Stopping the infusion immediately and notifying the provider is not necessary unless there is a clear indication of a serious issue (choice
C). Documenting the discrepancy and continuing monitoring without taking immediate action can compromise patient safety (choice
D).
Extract:
A nurse is caring for a client of a psychiatric unit
Nurses' Notes
0700
Client is admitted to the unit. They deny suicidal ideations at this time. Client states, "I am an
assistant to a powerful spirit." Client is poorly groomed and has body odor.
0900:
Called to the client's room, Client states, "I cannot believe you put me in a room with spiders on
the wall. " Client requests immediate transfer to another room.
1200:
Psychiatrist is at the bedside evaluating the client. After history and physical, psychiatrist states
that they have diagnosed the client with schizophrenia.
Client is to be started on medication and milieu therapy History and
Physical
0700
Majority of client's history is obtained from client's parent who presents with client today.
According to the parent, client has been acting strangely for a few months. Client's symptoms
have been progressively worsening.
In the last month, the client has been seeing things that are not present and believes that they are
in a close relationship with "a powerful spirit." Client has not been bathing regularly for the last
few weeks.
Client has no significant health history. Client reports that they do not take illicit substances or
drink alcohol. Client's grandparent has a history of schizophrenia
Question 2 of 5
For each potential action, click to specify if the action is indicated or contraindicated for the client.
| Potential Action | Indicated | Contraindicated |
|---|---|---|
| Allow the client to watch TV at high volume | ||
| Ask the client about the content of their hallucinations | ||
| Instruct the client on expected hygiene practices | ||
| Assess the client for suicidal ideation | ||
| Place the client in a room near the activity room |
Correct Answer: B,D
Rationale: [
B: Asking the client about the content of their hallucinations is indicated to gather important information for assessment and treatment planning.
D: Assessing the client for suicidal ideation is crucial to ensure their safety and provide appropriate interventions.
A: Allowing the client to watch TV at high volume is contraindicated as it may exacerbate symptoms or disturb others.
C: Instructing the client on expected hygiene practices may not be a priority compared to assessing hallucinations and suicidal ideation.
E: Placing the client in a room near the activity room is not mentioned in the question and does not address the client's immediate needs.]
Extract:
A nurse is caring for a client who is near the end of life and is on complete bed rest. The client states that he needs to have a bowel movement and the nurse offers a bed pan. The client states 'I've always used the bathroom'
Question 3 of 5
Which of the following responses should the nurse make?
Correct Answer: A
Rationale: The correct answer is A: "Tell me what concerns you about the bedpan." This response demonstrates active listening and empathy, allowing the nurse to understand the patient's specific worries or fears. It promotes patient-centered care by addressing the individual's needs. Other options lack this patient-centered approach: B assumes the patient can walk, C delegates without assessing the patient's concerns, and D is directive and dismissive of the patient's feelings.
Extract:
A nurse is caring for a client who is in labor Nurses' Notes
0900:
Contractions occurring every 3 to 4 min, lasting 80 to 90 seconds. Client rates pain with
contractions as 10 on a scale of 0 to 10 and requests an epidural.
Contractions approximately 4 min apart. Vaginal examination reveals cervix dilated 5 cm, 80%
effaced, -1 station, vertex presentation. FHR baseline 142/min with moderate variability. IV fluid
bolus initiated.
0930:
Epidural inserted by anesthesiology. Client reports pain as 2 on a scale of 0 to 10.
0950:
Spontaneous rupture of membranes with clear fluid. 1000:
Variable decelerations noted on the electronic fetal heart rate monitor tracing, FHR baseline
140/min, Deceleration 90/min, tasting 30 seconds: Loop of umbilical cord visible at vaginal
Vital Signs
0900:
Temperature 36.5 C (97.7 F) BP
130/84 mm Hg
Heart rate 108/min
Respiratory rate 18/min
Oxygen saturation 98% on room air
0930:
BP 120/78 mm Hg Heart rate
96/min Respiratory rate
18/min
Oxygen saturation 98% on room air
1000
BP 118/84 mm Hg Heart rate
95/min Respiratory rate
19/min
Oxygen saturation 97% on room air
Question 4 of 5
Select the 5 actions the nurse should take.
Correct Answer: A,B,C,D,E
Rationale:
Correct
Answer: A, B, C, D, E
Rationale:
A: Increasing IV fluid flow rate helps maintain hydration and blood pressure.
B: Notifying the provider ensures timely medical intervention and documentation.
C: Placing the client in Trendelenburg position helps improve placental perfusion.
D: Exerting upward pressure on presenting part can alleviate pressure on the cord.
E: Attempting to push the umbilical cord back can prevent cord compression and fetal distress.
Summary:
F: Administering oxygen may be beneficial but not among the immediate actions required.
G: No information provided about this choice.
Extract:
A nurse is providing an in service about client evacuation during the fracture.
Question 5 of 5
Which of the following clients should the nurse instruct the staff to evacuate first?
Correct Answer: C
Rationale: The correct answer is C: A client who is ambulatory and receiving oxygen. This client should be evacuated first because they are at risk for oxygen-related complications during an emergency. Oxygen supports combustion, increasing the risk of fire. The priority is to remove this client from the area to prevent harm. The other choices are incorrect because: A: Although the client is confused and uses a wheelchair, they are not at immediate risk of harm related to their condition. B: The client who is bedridden and wears a hearing aid is also not at immediate risk of harm. D: The client with a fracture in balance suspension traction can be safely evacuated with assistance and does not have an immediate life-threatening condition.