NGN ATI RN Comprehensive 2023 B Version 2 | Questions and Verified Answers| 100% Correct| A Grade
QUESTION
A nurse is assessing a newborn who is 3 d... [Show More] ays old. History and Physical
Newborn was delivered at 37 weeks of gestation via cesarean section for fetal distress.Apgar scores: 8 at 1 min and 9 at 5 min.Birth weight: 2.9 kg (6 lb 6 oz)The client who gave birth plans to breastfeed.
Flow Sheet
Day 2 of Life, 0900:
Temperature 36.7° C (98.1° F)Heart rate 140/minRespiratory rate 48/minWeight
2.7 kg (6 lb); 6% weight lossDay 3 of Life, 0800:
Temperature 36.4° C (97.5° F)Heart rate 140/minRespiratory rate 48/min Weight
2.5 kg (5 lb 9 oz); 12% weight loss
Nurses' Notes
Day 3 of Life, 0800:
Skin color consistent with newborn's genetic background. Respirations easy and unlabored. Abdomen soft with active bowel sounds. Mild tremors noted when awake. Anterior fontanel level and soft. Large ecchymotic caput suc- cedaneum noted on posterior scalp. Small amount of bloody mucus discharge
noted from vagina. Breastfeeding every 3 to 5 h
Answer:
When recognizing cues, the nurse should identify that a temperature of 36.4° C (97.5° F) is below the expected reference range. Hypothermia can lead to the occurrence of hypoglycemia and respi- ratory distress. The newborn breastfeeding for short intervals, nipple discomfort, and a weight loss of greater than 10% of birth weight can indicate inadequate transfer of breastmilk, which can result in hypoglycemia. The presence of mild tremors can be a manifestation of hypoglycemia.
QUESTION
A nurse on an antepartum unit is caring for a client who is at 33 weeks of gestation.
Diagnostic Results
WBC count 9,800/mm3 (5,000 to 10,000/mm3)Hgb 13 g/dL (greater than 11 g/dL)Hct 41% (greater than 33%)Platelet count 170,000/mm3 (150,000 to
400,000/mm3)BUN 20 mg/dL (10 to 20 mg/dL)Lactate dehydrogenase (LDH)
80 units/L (100 to 190 units/L)Aspartate aminotransferase (AST) 18 units/L (0 to 35 units/L) Alanine aminotransferase (ALT) 19 units/L (4 to 36 units/L)Uric acid (serum) 5.4 mg/dL (2.7 to 7.3 mg/dL)Kleihauer-Betke (fetal hemoglobin test) 3% (less than 1%)Blood type: Arh: positiveUrine reagent stripGlucose: nonepH: 6Specific gravity: 1.020Ketones: noneNitrates: noneLeukocyte es- terase: negativeProtein: negativeNitrites: none
Answer:
actions:
avoid cervical exam & insert large bore IV catheter experiencing:
abruptio placentae parameters to monitor: BP & Platelet count
The nurse should avoid cervical examination and insert a large-bore IV catheter because the client is most likely experiencing abruptio placentae indicated by the sudden onset of abdominal pain, contractions, and dark red vaginal bleeding. Cer- vical examination can cause further damage to the placenta and increase bleeding. The nurse should immediately establish IV access with a large-bore catheter to administer IV fluids and blood products if bleeding increases or if manifestations of fetal distress occur.
The nurse should monitor the client's blood pressure and platelet count because of the risk of significant blood loss due to the abruption. Hemorrhage might not be visible as vaginal bleeding if it is concealed between the placenta and uterine
wall. Therefore, manifestations of hypovolemic shock (decreasing blood pressure, increasing heart rate) can provide indications that internal placental bleeding is worsening. Abruptio placentae can also lead to alterations in coagulation, such
as disseminated intravascular coagulation, further increasing the client's risk for hemorrhage. Therefore, the nurse should monitor the client's platelet count to identify if the client is at an increased risk for bleeding.
24. when caring for a child, a nurse plans to use nonpharmacological inter- ventions to enhance the effectiveness of pain meds. which of the following strategies incorporates visualization techniques to help dec the child's dis- comfort?
Answer:
Blowing bubbles with liquid soap to "blow the hurt away"
Having the child blow bubbles is a visualization technique that can help to decrease the child's discomfort. The child can visualize the pain as the bubble that they blow away from themself and into the air.
QUESTION
A nurse is caring for a client in the emergency department (ED).
Nurses' Notes
0600:
Client admitted to the ED with fatigue, shortness of breath, and weakness for the last 2 days. Client states that they have a history of sickle cell disease (SCD). Client is alert and orientated to person, place, and time. Restless. Client rates generalized pain as a 9 on a scale of 0 to 10. Vital signs taken and blood drawn for laboratory tests. Oxygen 2 L via nasal cannula applied. Awaiting prescription for pain management.
0615 :
Client still rates pain as a 9 on a scale of 0 to 10. Hydromorphone 4 mg IV administered.
Answer:
When taking actions, the nurse should administer IV fluids, use humidification with oxygen therapy, and assess the client's mouth every 8 hr and peripheral circulation hourly. Hydration is a priority when caring for a client in sickle cell crisis because it decreases the rate of cell sickling and can reduce pain. Hypo- tonic fluids are typically infused at 250 mL/hr for 4 hr. Oxygen administered without humidification can cause drying of the mucous membranes, especially in clients who are already fluid-depleted. Placing humidification on the oxygen therapy promotes comfort and reduces the risk of sores and lesions of the mucous membranes. The nurse should assess the client's peripheral circulation because of the risk of venous occlusion caused by the sickling and clumping of the red blood cells and assess the client's mouth at least every 8 hr for the presence of sores or lesions and any other signs of infection.
QUESTION
A nurse in an outpatient mental health clinic is caring for a client.
Nurses' Notes
3 months ago:
Client recently admitted with new diagnosis of schizophrenia. Received inpa- tient treatment for 10 days and was discharged 1 week ago. Client is alert and oriented to person, place, time, and situation. Responds appropriately to ques- tions. Client reports sleeping well and working at a local retail store.Today: Client presents for follow-up visit. Pressured speech noted. Appears to be listening to unseen others. Client is restless. Frequently getting out of chair. Appears tired and disheveled.
Answer:
When recognizing cues, the nurse should identify that the findings of restlessness, auditory hallucinations, and pressured speech require immediate follow up. These findings are indications of psychosis. The nurse should notify the provider for additional evaluation and treatment.
QUESTION
A nurse is caring for a 1-month-old infant.
Nurses' Notes
1500:
Infant admitted to the pediatric unit. Parent reports infant has been irritable and has vomited after each feeding within the last 3 days.Infant alert, not crying. S1 and S2 noted without murmurs. Lungs clear to auscultation an- terior/posterior. Respirations even, unlabored. Abdomen firm. Bowel sounds hypoactive in all 4 quadrants. Small 1 x 1 cm2 mass palpated near umbilicus. Skin warm and dry, turgor with tenting.
1600:
Called to room by parent. The client who gave birth attempted breastfeeding. Infant projectile vomited. No bile noted in vomit. Some blood-tinged vomitus noted. Instructed parent to keep child NPO.
1800:
Infant crying. Soothed with pacifier.
Answer:
When prioritizing hypotheses and using the urgent vs. nonurgent priority framework, the nurse should identify that the infant
is at the greatest risk for developing dehydration due to a loss of gastric content from vomiting. An infant with pyloric stenosis presents with projectile vomiting after feeding, distended abdomen, and olive-shaped mass in the epigastrium.
28. A nurse is caring for a client who is postoperative following an appendec- tomy.
Nurses' Notes
1800:
Client alert and oriented to person, place, time, and situation.Skin warm and dry.Lungs clear on auscultationBowel sounds hypoactive in all four quad- rants.Urine clear yellowIncisional dressing clean and dry.Client reports pain as 6 on a scale of 0 to 10.
1815:
Morphine administered as prescribed.
2000:
Client reports abdominal pain as 10 on a scale of 0 to 10.Client reports nausea, no vomiting.Incisional dressing is dry and intact with no breakthrough bleed- ing noted.Lung sounds are clear to auscultation.Hypoactive bowel sounds present in all four quadrants.
Answer:
When recognizing cues, the nurse should identify that the findings of pain, nausea, heart rate, and oxygen saturation are unexpected findings for a client who is postoperative following an appendectomy. These findings should be reported to the provider.
QUESTION
A nurse is caring for a 5-year-old child.
Physical Examination
1510:
Upon visual inspection, throat is inflamed, tonsils appear pink, reddened and epiglottis is edematous and cherry red in appearance. Skin appears pale. Stridor noted upon inspiration with diminished bilateral lung sounds.
1500:
Child accompanied to emergency department by caregiver. Caregiver states child has a sore throat and reports the child has "pain on swallowing" and denies cough. Child is agitated and leaning forward with drooling noted.
1505:
Axillary temperature 38.8° C (102° F)Heart rate 130/minRespiratory rate
28/minBlood pressure 99/58 mm HgOxygen saturation 90% on room air
Answer:
The nurse should anticipate initiating droplet precautions and requesting a prescription for IV antibiotics. The child is most likely experiencing epiglottitis because of the clinical manifestations of a high fever, inflammation and redness of the throat, pale skin, stridor with inspiration, painful swallowing, no cough, is sitting in tripod position, and drooling. The nurse should monitor the child's temperature and breath sounds. [Show Less]
