ATI RN
ATI Comprehensive 2023 With NGN 180 Questions And Answers Questions
Extract:
A community health nurse is working with a family that is struggling to adapt following the loss of a family member.
Question 1 of 5
Which of the following actions should the nurse take first?
Correct Answer: B
Rationale: The correct answer is B: Determine the roles of individual family members. This is the first action the nurse should take because it helps identify each family member's strengths and capabilities, facilitating effective delegation of tasks. By determining roles, the family can work together efficiently to address the situation. Encouraging specific tasks (choice
A) and establishing a routine (choice
C) may come after roles are determined. Referring the family to a support group (choice
D) is important but not the initial step.
Extract:
A nurse is caring for a client who was at 33 weeks of gestation following an amniocentesis.
Question 2 of 5
Which complication should the nurse monitor for?
Correct Answer: A
Rationale: The correct answer is A: Contractions. Monitoring contractions is crucial in pregnancy to detect preterm labor, which can lead to serious complications. Increased fetal movement (
B) is a normal sign of fetal well-being. Hypertension (
C) is a concern but not the most immediate complication. Hypoglycemia (
D) is not a common complication in pregnancy unless the mother has pre-existing diabetes.
Extract:
A nurse in a long-term care facility is admitting a client with dementia.
Question 3 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 planning care for a client who is scheduled to receive a transfusion of packed RBCs.
Question 4 of 5
Which of the following actions should the nurse plan to take?
Correct Answer: A
Rationale: The correct answer is A: Use a solution of 0.9% sodium chloride to flush the transfusion tubing. This is important to prevent any reactions or interactions between different solutions. Using sodium chloride ensures compatibility and safety during the transfusion process.
Choice B is incorrect because lactated Ringer's solution should not be used to flush the tubing as it can cause adverse reactions.
Choice C is incorrect as a larger gauge IV catheter is recommended for blood transfusions to prevent hemolysis.
Choice D is incorrect as blood transfusions are typically infused over 2-4 hours, not 6 hours, to reduce the risk of complications.
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 were diagnosed with gestational diabetes at 28 weeks of gestation.
Vital Signs
2000:
Temperature 36.7° C (98.1° F)
Heart rate 98/min
Respiratory rate 20/min
Blood pressure 128/84 mm Hg
Oxygen saturation 98% on room air
Question 5 of 5
Select the 2 findings that require immediate follow-up.
Correct Answer: C,E
Rationale: An elevated fetal heart rate and meconium-stained amniotic fluid indicate potential distress, necessitating urgent intervention.