ATI RN
ATI Comprehensive 2023 With NGN 180 Questions And Answers Questions
Extract:
A nurse is reading a tuberculin skin test for a client who received a protein derivative test 72 hours ago.
Question 1 of 5
Which of the following findings indicate a positive test?
Correct Answer: A
Rationale: The correct answer is A because an induration measuring 10 mm is considered a positive test for certain skin tests, such as Tuberculin skin test. A larger induration size indicates a stronger immune response to the antigen injected.
Choice B is incorrect as redness without induration is not a reliable indicator of a positive test.
Choice C is incorrect as an induration measuring 3 mm is usually considered negative.
Choice D is incorrect as a blister at the injection site is not typically associated with a positive skin test result.
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 teaching a newly licensed nurse about caring for clients in the emergency department.
Question 3 of 5
Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?
Correct Answer: B
Rationale: The correct answer is B: Tell the client, 'You seem to be very upset.' This response shows empathy and validates the client's feelings, which can help de-escalate the situation. It acknowledges the client's emotions without escalating them further. Initiating seclusion protocol (
A) is inappropriate as it can escalate the situation and is a last resort for safety. Standing directly in front of the client and maintaining eye contact (
C) can be perceived as confrontational and may escalate the situation. Speaking in a firm and authoritative tone (
D) can further aggravate the client and escalate the situation.
Extract:
Question 4 of 5
A nurse in emergency department is caring for a three-year old child who has suspected epiglottitis. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct answer is A: Prepare to assist with intubation. In suspected epiglottitis, there is a risk of airway obstruction due to swelling of the epiglottis. Intubation may be necessary to secure the airway and ensure adequate oxygenation. This is a critical intervention to prevent respiratory distress and potential respiratory arrest. Obtaining a throat culture (
B) may be important for diagnosis but is not the immediate priority. Suctioning the oropharynx (
C) can stimulate the epiglottis and worsen the obstruction. Using a cool mist tent (
D) is not indicated in this emergency situation.
Extract:
A nurse is developing a nutritional care plan for a client who has COPD and severe dyspnea.
Question 5 of 5
Which action should the nurse include in the plan?
Correct Answer: B
Rationale: Small, frequent meals reduce fatigue and improve intake in clients with COPD.