All Documents for ATI Comprehensive Predictor
ATI COMPREHENSIVE ATI A
1. A nurse in a LTC facility notices a client who has Alzheimer’s disease standing at the exit door at the end of the hallway. The client appears to be anxious & agitated. What action should the nurse take? ANS: Escort the cl...
All Documents for ATI Comprehensive Predictor
ATI COMPREHENSIVE ATI A
1. A nurse in a LTC facility notices a client who has Alzheimer’s disease standing at the exit door at the end of
the hallway. The client appears to be anxious & agitated. What action should the nurse take? ANS: Escort the
client to a quiet area on the nursing unit.
- A client c Alzheimer experiences chronic confusion. Guiding the client to a quiet, familiar area will help decrease
agitation. They will be unable to follow instructions/commands.
2. A nurse is assisting with the plan of care for a client who has a continent urinary diversion. Which intervention
should the nurse plan to implement to facilitate urinary elimination?
ANS: Use intermittent urinary catheterization for the client at regular intervals.
- A continent urinary diversion contains valves that prevent urine from exiting the pouch; therefore, the nurse
should plan to insert a urinary catheter at regular intervals to drain urine from the client’s pouch.
3. A nurse is assisting with an education program about car restraint safety for a group of parents. Which
statement by the parent indicates an understanding of the instructions?
ANS: “My 12YO child should place the shoulder-lap seatbelt low across his hips.”
- When a child is old enough to only use a shoulder-lap seatbelt, he should place it low across his hips rather than
over the abdomen to reduce risk for injury during motor vehicle crash.
4. A nurse is reinforcing teaching about strategies to promote eating with a client who has COPD. Which
instructions should the nurse include in the teaching?
ANS: Drink high-protein and high-calorie nutritional supplements.
- The nurse should instruct the client to drink high-protein and high-calorie nutritional supplements to maintain
respiratory muscle function. COPD causes respiratory stress that leads to hypermetabolism and wasting of the
client’s muscle mass.
5. When removing PPE after direct care for a client who requires airborne & contact precautions, which PPE
is removed first? ANS: Gloves
- The greatest risk is contamination from pathogens that might be present on the PPE; therefore, the priority
action for the AP is to remove the gloves, which are considered the most contaminated.
6. A nurse is inspecting the skin of a newborn. Which finding should the nurse report to the PCP?
ANS: Generalized Petechiae
- Petechiae are an expected finding over the presenting part of the newborn, such as on the forehead in a brow
presentation, & also anywhere on the head of infants who had a nuchal cord, w/c is an umbilical cord around
the neck. However, petechiae all over the newborn’s body can indicate infection or decreased platelet count
and should be reported to the provider.
7. A nurse is contributing to a teaching plan for a group of male adolescents about the A/E of anabolic steroid use.
Which manifestations should the nurse include?
ANS: Reduced height potential
- Use of anabolic steroids in adolescence can lead to premature epiphyseal closure, thus reducing full height
potential. A/E includes: Liver disorders, hyperlipidemia, breast enlargement, acne, and edema.
8. A nurse is reinforcing teaching with an older adult client who has severe L-sided HF. Which statement should the
nurse make?
ANS: Rest for 15 minutes between activities.
- The nurse should instruct to increase his activity gradually & to rest for a period of 15 min if he becomes tired.
Clients who have HF should balance activity c rest to reduce cardiac workload.
9. A nurse in a LTC facility is documenting the care of an older adult client. Which information should be included in
weekly nursing care summary? ANS: Hydration Status
- Older adult client are at risk for dehydration. Therefore, the nurse should be vigilant about monitoring the
client’s hydration status & include this information in the weekly nursing care summary.
,10. A nurse is caring for a client who has a head injury. Using the Glasgow Coma Scale to collect data, the
nurse should obtain which information? ANS: Motor Response
- The nurse should collect data about the client’s motor response & assign the response a score of 1-6, according
to the Glasgow Coma Scale.
11. A home health nurse is reinforcing teaching with a client about the use of elastic stockings to decrease
peripheral edema. Which instruction should the nurse include? ANS: Apply the stocking in the morning.
- The nurse should instruct the client to apply the elastic stocking in the morning and remove them at the end of
the day before bedtime.
12. A nurse is obtaining health hx from a client who is scheduled to undergo cardiac catheterization in 2 days. Which
questions is the priority for the nurse to ask?
ANS: “Do you know if you’re allergic to iodine?”
- The greatest risk to the client is an allergic reaction to the contrast agent, which contains iodine.
13. A nurse is planning to administer nystatin oral suspension to a client who has oral candidiasis. Which instructions
should the nurse give?
ANS: “Hold the medication in your mouth for several minutes prior to swallowing”
- The client should swish & hold the liquid in the mouth for at least 2 min to facilitate contact of the medication
with the organism. The client should then swallow or spit out the medication.
14. A nurse is preparing to care for the assigned clients on her upcoming shift. Which time management strategies
should the nurse plan to use?
ANS: Prepare a priority list of client needs for the shift.
- The nurse should prepare a client priority-to-do list, which could include administering time-critical medications.
This will allow the nurse to determine which clients should receive care first.
15. After witnessing the consent, what action should the nurse take next?
ANS: Ask client what he understands about the procedure.
16. Which task should the nurse assign to an AP for a pt 2 days post-op ff Total knee arthroplasty?
ANS: Reapply antiembolitic stockings to the client ff a shower.
17. A nurse is reinforcing teaching with a client who is receiving radiation therapy for cancer of the larynx. Which
statement made by the client indicates understanding of the teaching? ANS: “I will wear a soft scarf around my
neck when I am outside”
- Wash it with plain water without soap. NO heat source therapy. Only use electric razor if necessary, for shaving.
18. A nurse is using FLACC scale to determine the level of pain for an 11-months-old infant who sis port-op.
Which factor should the nurse consider when using this pain scale? ANS: Level Of Activity
- The nurse should consider the infants level of activity when using FLACC pain scale. The FLACC is determined by
five categories of behavior: Facial Expression, Leg Movement, Activity, and Consolability.
19. A nurse is collecting data from a 5YO child at a well-child visit. Parent reports that the child is having frequent
nightmares. Which statements by the parents indicates to the nurse that the child Is experiencing sleep terrors
rather than nightmares?
ANS: “My child goes back to sleep right away.”
- The nurse should realize that going back to sleep quickly is an indication of sleep terrors, rather than nightmares.
A child who is experiencing nightmare has difficulty returning to sleep because of continued fear.
20. A nurse is assisting with the care of a school-age child immediately ff surgery. The child weighs 21.8 kg (48 lb)
& has a chest tube applied to suction. Which finding should the nurse report to PCP? ANS: 250 mL of
sanguineous drainage over the last 3 hr
- More than 3 mL/kg/hr of sanguineous drainage occurs for more than 2-3 consecutive hr ff surgery. It indicates
active hemorrhaging.
21. A nurse is reinforcing teaching with an older adult client who has osteoarthritis. Which instructions should the
nurse include?
ANS: Apply capsaicin cream 4x/day
- Apply it topically to provide warmth & relieve joint pain.
, 22. A nurse is reinforcing teaching about managing manifestation of anxiety with a client who has
generalized anxiety disorder. Which information should the nurse include? ANS: Say the word “STOP”
when upsetting thoughts occur.
23. A nurse in a LTC facility is collecting data form a client who has been receiving betaxolol to treat
glaucoma. Which findings is an A/E if this medication? ANS: Bradycardia
- Betaxolol is a beta blocker that can produce systemic effects, including bradycardia.
24. A nurse in an outpatient surgery center is reinforcing discharge teaching with a client ff a lithotripsy for uric
acid stones. Which instructions should the nurse plan to include? ANS: Strain the urine to collect stone
fragments.
25. A nurse in a provider’s office is reinforcing teaching with a client who is to follow a 2,000 mg sodium-restricted
diet. Which client food selections indicates understanding of the teaching? ANS: Canned Peaches.
26. A nurse is preparing to perform a bladder scan for a client. Which action should the nurse take?
ANS: Tell the client she should not experience any discomfort.
27. A nurse is contributing to the plan of care for a client who has a prescription for ROM exercises of the shoulder.
Which exercise should the nurse recommend promoting shoulder hyperextension?
ANS: Move her arm behind her body with her elbow straight.
28. A nurse is collecting data from an older adult client who has a gastric ulcer. Which finding should the nurse
identify as a complication to report to the provider? ANS: Hematemesis
29. A nurse is discussing the use of epidural analgesia with a newly licensed nurse. Which statement by the newly
licensed nurse indicates understanding of this method of pain control?
ANS: “I should report leaking at the insertion site to the anesthesiologist”
30. A nurse is contributing to the plan of care for a client who is receiving continuous bladder irrigation
immediately ff a transurethral resection of the prostate (TURP). Which of the ff interventions should the nurse
include? ANS: Maintain a drainage flow rate to keep the urine diluted to a reddish-pink color.
31. A nurse is caring for a client who is scheduled for a mastectomy the ff day. The client is tearful & tells the nurse
that she is not ready to have this procedure done at this time. What response should the nurse give? ANS:
“Would you like for me to talk to the surgeon with you?”
32. A nurse is collecting data from a school-age child who has hypoglycemia. What is the manifestation to expect?
ANS: Sweating
33. A nurse is assisting with a community education program for parents of preschoolers about recommended
activities to promote physical development. Which of the ff statement should the nurse make? ANS: “You
should provide unorganized play activities for your child each day.”
34. A nurse is collecting data from a client who has chronic pancreatitis and is receiving pancrelipase. Which
findings indicates the client is experiencing a therapeutic response to this medication?
ANS: Report of a decrease in the number of stools.
- Pancrelipase is administered as a replacement therapy for a deficiency in pancreatic enzymes, which results in
steatorrhea, or fatty stools.
35. A nurse is caring for a client who is 12-hour post-op ff total knee arthroplasty. What action should the nurse
take?
ANS: Place an abduction wedge between the client’s legs when he is in bed.
36. A nurse is reinforcing teaching regarding puberty with a group of prepubescent female clients. Which
information should the nurse include in the teaching?
ANS: “You will gain weight before you start to get taller.”
37. NO ORAL CONTARCEPTIVES for CAD
38. A nurse is caring for a client who is at 34 weeks gestation and has mild preeclampsia. Which finding indicates a
progression from mild to severe preeclampsia? ANS: Client reports of blurred vision.
39. A nurse is reinforcing teaching with a client who has asthma & has a prescription of theophylline. What
statement should the nurse make?
ANS: Discontinue drinking caffeinated beverages.
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