ATI RN
ATI Comprehensive 2023 With NGN 180 Questions And Answers Questions
Extract:
A nurse is assessing a client who has a possible right pneumothorax.
Question 1 of 5
Which of the following findings should the nurse expect?
Correct Answer: A
Rationale: The correct answer is A: Reduced right-sided breath sounds. This finding is indicative of a possible pneumothorax on the right side. Pneumothorax causes the lung to collapse, resulting in decreased or absent breath sounds on that side. Intercostal retractions (
B) typically indicate increased work of breathing, not specific to pneumothorax. High-pitched stridor (
C) is associated with upper airway obstruction, not pneumothorax. Paradoxical chest movement (
D) is seen in flail chest, not pneumothorax.
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 was diagnosed with gestational diabetes at 28 weeks of gestation.
2020:
Contractions occurring every 4 to 5 min, lasting 40 to 60 seconds. Small amount of bloody show
noted when changing disposable pad on bed. Client rates contraction pain as a 5 on a scale of 0
to 10, breathing well through contractions., FHR 168/min, minimal variability. Client denies
epigastric pain or visual disturbances. Trace of edema noted to bilateral lower extremities.
Question 2 of 5
For each potential intervention, click to specify if the intervention is anticipated or contraindicated for the client.
| Potential Intervention | Anticipated | Contraindicated |
|---|---|---|
| Monitor blood pressure every hour | ||
| Maintain continuous monitoring of the FHR | ||
| Initiate an IV infusion of lactated Ringers | ||
| Place the client in a left lateral position |
Correct Answer: A,B,D
Rationale: Monitoring blood pressure, maintaining continuous FHR monitoring, and placing the client in a left lateral position are all anticipated interventions in labor management.
Extract:
A nurse is reading a tuberculin skin test for a client who received a protein derivative test 72 hours ago.
Question 3 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:
Question 4 of 5
A nurse is providing teaching to a client who is 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching?
Correct Answer: C
Rationale: The correct answer is C: Swelling of the face. Swelling of the face can be a sign of preeclampsia, a serious condition in pregnancy characterized by high blood pressure and protein in the urine. This finding should be reported to the provider immediately to prevent complications for both the mother and the baby.
Bleeding gums (
A) are common in pregnancy due to hormonal changes and increased blood flow to the gums. Faintness upon rising (
B) can be attributed to postural hypotension, which is common in pregnancy but not typically a serious concern. Urinary frequency (
D) is a common complaint in pregnancy due to the growing uterus putting pressure on the bladder.
In summary, while the other symptoms may be common in pregnancy, swelling of the face is the most concerning finding that could indicate a serious complication like preeclampsia, making it crucial to report to the provider promptly.
Question 5 of 5
A nurse is performing a neurological examination on a client as part of a complete physical assessment. The nurse should identify that cranial nerve XI(11) is intact when the client performs which of the following actions?
Correct Answer: A
Rationale: The correct answer is A: Shrugs his shoulders. Cranial nerve XI, also known as the accessory nerve, controls the movement of the sternocleidomastoid and trapezius muscles. When the client shrugs his shoulders, the nurse is assessing the function of these muscles, which are innervated by cranial nerve XI. This action indicates the integrity of the nerve.
Other choices are incorrect because:
B: Smiling symmetrically is controlled by cranial nerve VII (facial nerve).
C: Closing eyes tightly is controlled by cranial nerve VII (facial nerve).
D: Identifying a familiar scent is controlled by cranial nerve I (olfactory nerve).