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 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.
2230:
Contractions occurring every 2.5 to 3 minutes, lasting 60 to 70 seconds. Epidural placed by
anesthesiologist. Client rates pain with contractions as a 3 on a scale of 0 to 10. FHR 150/min
with moderate variability. Accelerations present, no decelerations noted.
Vital Signs
2230:
Temperature 38° C (100.4° F)
Heart rate 88/min
Respiratory rate 16/min
Blood pressure 122/80 mm Hg
Oxygen saturation 98% on room air

Select the findings that indicate the interventions have been effective.

  • A. Client rates pain with contractions as a 3 on a scale of 0 to 10
  • B. Contractions occurring every 2.5 to 3 minutes, lasting 60 to 70 seconds
  • C. Accelerations present, no decelerations noted
  • D. Heart rate 88/min
  • E. Blood pressure 122/80 mm Hg
  • F. Temperature 38° C(100.4° F)
Correct Answer: A,C

Rationale: Effective pain relief (client rates pain as 3) and normal FHR patterns indicate successful interventions.

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A charge nurse is observing A newly licensed nurse provide care for a client who is post-operative. The newly licensed nurse tells the client that she will insert a urinary catheter if the client will not void.

Which of the following torts should the charge nurse identify as having occurred?

  • A. Assault
  • B. Battery
  • C. False imprisonment
  • D. Negligence
Correct Answer: A

Rationale: The charge nurse should identify assault as having occurred. Assault is the intentional act that causes a person to fear they will be harmed. In this case, if a healthcare provider threatens a patient with a procedure without their consent, it constitutes assault. Battery, on the other hand, is the intentional harmful or offensive touching of a person without consent. False imprisonment involves restraining a person against their will, which is not described in the scenario. Negligence refers to a failure to exercise reasonable care, and it does not apply here as the situation involves intentional actions.

A nurse is caring for a client who has an implanted venous access port.

Which of the following should the nurse use to assess the port?

  • A. An Angio catheter
  • B. A butterfly needle
  • C. A noncoring needle
  • D. A 25-gauge needle
Correct Answer: C

Rationale: The correct answer is C: A noncoring needle. To assess a port, a noncoring needle should be used because it is specifically designed for accessing ports without damaging the septum. Using an Angio catheter (A) may be too large and cause damage, a butterfly needle (B) is not suitable for accessing ports, and a 25-gauge needle (D) may be too small or not specifically designed for port access. Noncoring needles are the standard choice for accessing ports due to their design that minimizes trauma and ensures proper function.

A nurse is caring for a client who has diabetes mellitus and is receiving long-acting insulin for blood glucose management.

Which type of insulin should the nurse anticipate administering?

  • A. Glargine insulin.
  • B. Regular insulin.
  • C. NPH insulin.
  • D. Insulin aspart.
Correct Answer: A

Rationale: The correct answer is A: Glargine insulin because it is a long-acting insulin with a duration of action of up to 24 hours, providing a basal level of insulin throughout the day. It is typically administered once daily at the same time each day to maintain stable blood glucose levels. Regular insulin (B) is short-acting and is usually given before meals. NPH insulin (C) is intermediate-acting and has a peak action of 4-12 hours. Insulin aspart (D) is a rapid-acting insulin used for mealtime coverage. In this scenario, the nurse should anticipate administering Glargine insulin for its long-acting, basal properties.

A nurse is preparing to administer the first dose of cefazolin via intermittent IV infusion to a client.

Which of the following actions should the nurse take first?

  • A. Review the client's allergy history.
  • B. Monitor the client's temperature.
  • C. Check the client's latest white blood cell(WBC) count.
  • D. Explain the purpose of the medication to the client.
Correct Answer: A

Rationale: The correct answer is A: Review the client's allergy history. This should be done first to prevent potential harm to the client from allergic reactions. Knowing the client's allergy history helps the nurse identify any potential risks associated with administering medications. Monitoring temperature (B) and checking WBC count (C) are important but come after ensuring the safety of medication administration. Explaining the purpose of medication (D) is important but should be done after ensuring the client's safety.

The charge nurse on a medical surgical unit is assisting with the emergency response plan following an external disaster in the community.

In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?

  • A. A client who was one day postoperative following a vertebroplasty.
  • B. A client receiving IV antibiotics for pneumonia with a fever of 101°F(38.3°C).
  • C. A client who had a transient ischemic attack(TIA) 12 hours ago and is awaiting further evaluation.
  • D. A client with uncontrolled atrial fibrillation requiring continuous cardiac monitoring.
Correct Answer: A

Rationale: The correct answer is A. The client one day postoperative following a vertebroplasty can be recommended for early discharge as this procedure is typically short-stay and does not require extended monitoring. The client is likely stable and can continue recovery at home.

Choice B is incorrect because a client with pneumonia and a fever of 101°F requires continued IV antibiotics and monitoring to ensure resolution of infection and fever reduction.

Choice C is incorrect as a client with a recent TIA requires further evaluation and monitoring to prevent recurrent strokes and assess for potential complications.

Choice D is incorrect because a client with uncontrolled atrial fibrillation requiring continuous cardiac monitoring should not be discharged early as they need close monitoring and management to prevent complications like stroke or heart failure.

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