ATI RN
ATI Comprehensive 2023 With NGN 180 Questions And Answers Questions
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 1 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 2 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 3 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.
Extract:
A nurse is caring for a client who is 4 days postpartum following a cesarean birth
Nurses’ Notes
Today
0800
Client reports not feeling well with headache, body aches, and chills. Left breast red and tender
with swollen, tender lymph nodes in the left axilla. Incision edges well approximated without
erythema or drainage. Small amount of Lochia rubra noted.
0830
Provider notified of findings. Prescriptions received.
Question 4 of 5
For each potential assessment finding, click to specify if the assessment finding is consistent with mastitis or endometritis.
| Assessment Findings | Mastitis | Endometritis |
|---|---|---|
| Foul-smelling lochia | ||
| Painful, tender breast | ||
| Temperature | ||
| Chills |
Correct Answer: B,C,D
Rationale:
The correct answer is B, C, D.
B: Painful, tender breast - This finding is consistent with mastitis, which is an infection of the breast tissue.
C: Temperature - This finding is common in both mastitis and endometritis, indicating an infection.
D: Chills - This finding is more indicative of a systemic infection, often seen in endometritis.
Explanation for incorrect choices:
A: Foul-smelling lochia - This finding is more specific to endometritis, not mastitis.
E, F, G: Since these parameters are not provided, they cannot be selected or checked.
Extract:
A nurse is assessing a client who has a possible right pneumothorax.
Question 5 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 suggests a potential pneumothorax on the right side, where air leaks into the pleural space causing lung collapse and decreased breath sounds. Intercostal retractions (
B) indicate increased work of breathing, likely due to respiratory distress but not specific to a pneumothorax. High-pitched stridor (
C) is a sign of upper airway obstruction, not typically seen with pneumothorax. Paradoxical chest movement (
D) is seen in flail chest, not characteristic of pneumothorax.