ATI Comprehensive Predictor 2020 | ATI Comprehensive Predictor 2020 – Graded A

ATI Comprehensive Predictor 2020 – Chamberlain College of Nursing 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. ...

ATI Comprehensive Predictor 2020 – Chamberlain College of Nursing 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 timecritical 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. 40.A/E of metronidazole: Reddish-brown urine. 41. A home health nurse is collecting data from an older adult client who has generalized anxiety disorder. The client lives at home with her partner & sibling. Which responses by the client’s partner is the priority for the nurse to address? ANS: “Her prescription isn’t generic, so we can’t afford it anymore.” 42.Patient having difficulty using eating utensils. Refer patient to OT. 43.Child who have ingested full bottle of acetaminophen, instruct parents to take the child to the ER 44.A client requesting information from a nurse about creating a health care proxy. Which statement should the nurse make? ANS: “The person you appoint will make health care decisions for you if you cannot do so yourself.” 45. Venipuncture = antecubital fossa 46.The nurse should stop the infusion if the patient is having edema above the catheter insertion site. 47. A nurse is contributing to the plan of care for a client who has pneumonia. Which entries should the nurse include in the plan? ANS: “Client prefers bathing in the evening.” 48.Strategies to teach parents about pediculosis capitis (Head lice) management: ANS: Store child clothing in a separate cubicle when at school. Boil brushed and combs in water for 10 min. Dry bed linens & clothing in a hot dryer for at least 20 min. 49.Caring for a client who has GTube. What actions should the nurse take? ANS: Flush the tube with 50-60 mL of warm water if the tube becomes clogged. 50.Caring for client who is 4 hr post-op ff GI surgery & NG is placed for decompression. Which action should the nurse take? ANS: Keep the plugged tube above the level of the stomach when the client is ambulating. 51. Reinforcing teaching with a client who is scheduled for an exercise electrocardiography (ECG) stress test. What instruction to give? ANS: Recommend the client wear comfortable shoes during the test. - Informed consent must be signed, Instruct client to eat 2-3 hr before test and then remain NPO to prevent GI upset during test.52. A client who is Orthodox Judaism with terminal illness. The nurse should assure the client family member will stay with his body after death. 53. A client who has pneumonia and is currently receiving oral antibiotic may be discharged to have more rooms for new admission patient. 54. Avoid Ibuprofen when taking “PRIL” medications. 55. A nurse observes a client in labor. What interventions should the nurse recommend? ANS: Squatting using a birth ball, Counter pressure to the sacral area, & leaning forward while kneeling. 56. Sitting and leaning forward using both hands for support is an expected finding for a 7-month old infant. 57. Type 1 DM, patient indicates understanding of patient teaching when he/she states that, “I will dispose of my needles in a plastic laundry detergent container”. - It is puncture-proof! 58.Offer client a whole grain cracker before bedtime if they are having difficulty sleeping. 59. Red meat = iron 60.Peanut butter = protein 61. External rotation is a clinical manifestation to expect to a client with hip fx 62.“Let’s give the medication to your doll first” is an action the nurse should take prior to performing an immunization to a preschooler. 63.Dark green and viscous is the stool to expect 24 hrs after birth of an infant. 64.Atorvastatin A/E: Muscle Pain 65. Suggest walking outside with a staff member to a patient with bipolar disorder & in a manic phase. 66.An infection with gonorrhea may result to infertility. STI pt teaching 67. Physical neglect indication when collecting a from a toddler is when “the toddler is inadequately dressed for the weather” 68.Overdose digoxin? Check VS 69.Anorexia Nervosa care plan? Record I&O 70.Documenting client care in the medical record, entries to include would be “Client remains NPO until X-Ray procedure is complete” 71. To initiate Babinski reflex? Stroke the sole of the infant’s foot upward & toward the great toe. 72. Report an ECG result with PR interval 0.24 seconds. 73. When patient report of nuchal rigidity, H/A, along with fever & chills. The nurse should anticipate the MD to order what diagnostic tests? ANS: Cerebrospinal fluid analysis- The client findings are consistent with bacterial meningitis. A lumbar puncture should be performed to obtain cerebrospinal fluid to confirm the diagnosis. 74. Post-Op Lumbar puncture: Instruct patient to increase fluid intake. 75. The client must take montelukast once daily at bedtime. 76. Perform daily gum massage when taking phenytoin as a measure to assist with the possible A/E. 77. Lung sound: Wheezes 78. Morphine A/E: Respiratory Rate of 10/min 79. Document findings as a variance 80.pH 7.5 is a complication of mechanical ventilation 81. Recent confirmation of pregnancies 82.Spaghetti with red meat sauce 83.Urine specific gravity of 1.002 for pt with D - - - - - - - -Continued