ATI Comprehensive 2023 With NGN 180 Questions And Answers

ATI Comprehensive 2023 With NGN 180 Questions And Answers Related

Review ATI Comprehensive 2023 With NGN 180 Questions And Answers related questions and content

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.

For each nursing action, click to specify if the nursing action is essential or contraindicated for the client.

  • A. Assist the client with ambulation
  • B. Inform the client to expect drowsiness
  • C. Monitor for elevated temperature
  • D. Assess for urinary retention
  • E. 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.

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A nurse is planning care for a client who was receiving continuous internal tube feeding through an open system.

Which intervention should the nurse include in the plan of care?

  • A. Placing a formula in the container to last 18 hours
  • B. Flushing the feeding tube with water every 4 to 6 hours.
  • C. Covering and labeling the opened formula container with the date and time.
  • D. Elevating the head of the bed to at least 30 degrees during feeding.
  • E. Replacing the feeding container and tubing every 24 hours.
Correct Answer: E

Rationale: The correct answer is E, replacing the feeding container and tubing every 24 hours. This intervention is crucial to prevent bacterial contamination and ensure the patient's safety. By replacing the container and tubing regularly, the nurse helps maintain a sterile environment for the enteral feeding, reducing the risk of infection.

Choice A is incorrect because leaving formula in the container for 18 hours can lead to bacterial growth and contamination. Choice B, flushing the feeding tube with water every 4 to 6 hours, is important for tube patency but does not address the need for replacing the container and tubing. Choice C, covering and labeling the formula container, is a good practice for storage but does not address the need for regular replacement. Choice D, elevating the head of the bed during feeding, is important for preventing aspiration but is not directly related to the maintenance of feeding equipment.

A nurse is caring for an infant who has coarctation of the aorta.

Which finding should the nurse identify as expected?

  • A. Weak femoral pulses
  • B. Bounding pulses in the lower extremities
  • C. Cyanosis of the hands and feet
  • D. Frequent episodes of bradycardia
Correct Answer: A

Rationale: The correct answer is A: Weak femoral pulses. In pediatric patients, weak femoral pulses are expected due to the normal physiological differences in vascular resistance between upper and lower extremities. This is known as the "femoral pulse lag." Bounding pulses in the lower extremities (choice B) would be abnormal and could indicate a vascular disorder. Cyanosis of the hands and feet (choice C) suggests poor perfusion and oxygenation, which is concerning. Frequent episodes of bradycardia (choice D) could indicate cardiac issues and are not expected in a healthy pediatric patient.

A nurse is caring for a newborn.
Nurses' Notes
0640:
Weight 4200 gm (9 lb 4 oz), head circumference 35.5 cm (14 in)
Respiratory rate 68/min, with mild grunting.
0650:
Respiratory rate 72/min, with mild grunting
0700:
Respiratory rate 76/min, with moderate grunting and mild intercostal retractions.

The client is at risk for developing------- and----

  • A. bronchopulmonary dysplasia
  • B. transient tachypnea of the newborn
  • C. tachycardia
  • D. hypopycemia
Correct Answer: B,D

Rationale: Transient tachypnea and hypopycemia are common risks in newborns with respiratory distress.

A nurse in a family health clinic is caring for a client who requests information regarding the correct use of condoms.

Which of the following statements should the nurse make?

  • A. When using implanted contraceptive methods, condoms should also be used to protect against STDs.
  • B. Use of petroleum-based lubricant with a condom increases the condom's effectiveness
  • C. Ensure that the condom fits snugly over the tip of the penis
  • D. Condoms are equally effective for birth control with or without the use of vaginal spermicides
Correct Answer: A

Rationale: The correct answer is A. This statement is correct because implanted contraceptive methods, like hormonal implants, do not protect against sexually transmitted diseases (STDs), so using condoms is necessary for dual protection. Choice B is incorrect as petroleum-based lubricants can weaken condoms. Choice C is incorrect because a condom should fit comfortably, not snugly, to prevent breakage. Choice D is incorrect because condoms are more effective for birth control when used with spermicide.

A nurse in a clinic is planning care for a child who has ADHD and is taking atomoxetine

Which of the following laboratory values should the nurse monitor?

  • A. Liver function tests
  • B. kidney function tests
  • C. hemoglobin and hematocrit
  • D. serum sodium and potassium
Correct Answer: A

Rationale: The correct answer is A: Liver function tests. Monitoring liver function is crucial as it assesses the health of the liver, detecting any abnormalities or diseases. Liver function tests include assessing levels of enzymes, proteins, and bilirubin. Abnormal results can indicate liver damage or dysfunction. Monitoring kidney function (B) is important but not the priority in this scenario. Hemoglobin and hematocrit (C) are essential for assessing blood health but not specific to liver function. Serum sodium and potassium (D) are more related to electrolyte balance than liver function.

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