ATI RN VATI Comprehensive Predictor 2019 Form B
A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is
... [Show More] the nurse's priority? - ANSWER ==Assist with deep breathing and coughing
A nurse is talking with a client who has stage IV breast cancer. The nurse should recognize which of the following statements by the client as a constructive use of a defense mechanism? - ANSWER =="I told my doctor that I would like to start a support group for other women who are sick in my community"
A nurse is caring for a client who has immunosuppression and a continuous IV infusion.
Which of the following actions should the nurse take? - ANSWER ==Monitor the
client's mouth every 8 hr
A nurse is caring for a 2 month old infant who has Hirschsprung disease (HD). Which of
the following areas should the nurse assess for manifestations of HD? - ANSWER
,
==C
The nurse should assess the infant's abdomen for distention and visible peristalsis
which are manifestations of HD
A nurse at a mental health clinic is caring for four clients. The nurse should recognize the following clients is using dissociation as a defense mechanism? - ANSWER ==A client who was abused as a child describes the abuse as if it happened to someone else
A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes
mellitus. The nurse should instruct the client to monitor for which of the following
findings as a manifestation of hypoglycemia? - ANSWER ==irritability
A nurse in an outpatient mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is effectively using sublimation as a defense mechanism? - ANSWER ==A client who channels their energy into a new hobby following the loss of their job
A hospice nurse is consulting with a client and her family about receiving home services. Which of the following statements should the nurse identify as an indication that the family understands home hospice care? - ANSWER =="We can expect the hospice nurse to provide support for us after our mother's death"
A nurse is caring for a client who has active tuberculosis. Which of the following actions should the nurse take? - ANSWER ==Assign the client to a private room with negative air pressure
A nurse is providing teaching to a client who is at 24 weeks of gestation and is schedule
for a 3 hour oral glucose tolerance test. Which of the following instructions should the
nurse include in the teaching? - ANSWER =="You will need to fast the night before
the test"
A nurse on a pediatric unit has received change of shift report for four children. Which of the following children should the nurse assess first? - ANSWER ==A 10 year old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain
A nurse in a community center is providing an education session to a group of clients
about ovarian cancer. Which of the following manifestations of ovarian cancer should
the nurse include in the teaching? - ANSWER ==Abdominal bloating
A nurse is caring for a client who is postoperative after receiving moderate (conscious)
sedation. The client suddenly becomes restless and reports feeling lightheaded. Which
of the following actions should the nurse take? - ANSWER ==Check the client's
oxygen saturation level
A nurse is working in an emergency department is triaging four clients. Which of the
following clients should the nurse recommend for treatment first? - ANSWER ==A
middle adult client who has unstable vital signs
A nurse is providing teaching for a client who has a fracture of the right fibula with a short leg cast in place and a new prescription for crutches. The client is non-weight bearing for 6 weeks. Which of the following instructions should the nurse include in the teaching? - ANSWER ==Use a three-point gait
A nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client? - ANSWER ==Radial vein of the inner arm
A nurse is planning to delegate client care tasks to an AP. Which of the following tasks
should the nurse plan to delegate to the AP? - ANSWER ==Perform gastrostomy
feedings through a client's established gastrostomy tube
A nurse is caring for a newborn immediately after delivery. Which of the following interventions should the nurse implement to prevent heat loss by conduction? - ANSWER ==Use a protective cover on the scale when weighing the infant
A nurse is caring for a client who is receiving a continuous heparin infusion. Which of
the following laboratory tests should the nurse review prior to adjusting the client's
heparin? - ANSWER ==aPTT
A nurse administers an incorrect dose of medication to a client. The nurse recognized the error immediately and completes and incident report. Which of the following facts related to the incident should the nurse document in the client's medical record? - ANSWER ==Time the medication was given
A nurse is providing education to the parent of a school age child who has asthma. Which of the following statements by the parent indicates an understanding of the teaching? - ANSWER =="I will make sure my child receives a yearly influenza immunization"
A nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after falling off a step stool at home. Which of the following prescriptions should the nurse clarify with the provider? - ANSWER ==Apply a cold pack to the client's ankle for 30 min every hour
A nurse is assessing a client who has a major depressive disorder and is taking amitriptyline. Which of the following findings should the nurse identify as an adverse effect of the medication? - ANSWER ==Blurred vision
A nurse is caring for a client who has signed an informed consent form to receive electroconvulsive therapy (ECT). The client states to the nurse "I'm not sure about this now. I'm afraid it's too risky." Which of the following responses should the nurse make? - ANSWER =="You have the right to change your mind about the procedure at any time"
A nurse is preparing to administer mannitol 0.2 g/kg IV bolus over 5 min as a test dose
to a client who has severe oliguria. The client weighs 198 lb. What is the amount in
grams the nurse should administer? - ANSWER ==18 g
A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse plan to take? - ANSWER ==Use the ventrogluteal site
A nurse is providing discharge teaching to a client who is to receive home oxygen therapy. Which of the following instructions should the nurse include in the teaching? - ANSWER ==Wear clothing made with cotton fabrics while oxygen is in use
A nurse is providing teaching to the guardians of a newborn about measures to prevent sudden infant death syndrome (SIDS). Which of the following guardian statements indicates an understanding of the teaching? - ANSWER =="I will not allow anyone to smoke near my baby"
A nurse is assessing a client following a vaginal delivery and notes heavy loch and a
boggy fundus. Which of the following medications should the nurse expect to
administer? - ANSWER ==Oxytocin
A nurse on a medical-surgical unit is caring for a client who has a new diagnosis of terminal cancer. The client tells the nurse that they would like to go home to be with family and loved ones. Which of the following actions should the nurse take? - ANSWER ==Make a referral for social services
A nurse is caring for a client who has a clogged percutaneous gastrostomy feeding
tube. Which of the following actions should the nurse take first? - ANSWER
==Change the position of the client
A nurse is creating a plan of care for a client who has left-sided weakness following a
stroke. Which of the following interventions should the nurse include in the plan? -
ANSWER ==Support the client's left arm on a pillow while sitting
A nurse is preparing to assist with a thoracentesis for a client who has pleurisy. The nurse should plan to perform which of the following actions? - ANSWER ==Instruct the client to avoid coughing during the procedure
A charge nurse is providing an educational session about infection control for a group of staff nurses. Which of the following statements by one of the staff nurses indicated an understanding of isolation precautions? - ANSWER =="A client who requires airborne precautions should be placed in a negative pressure airflow room"
A nurse is providing dietary teaching to a client who has a new prescription for phenelzine. Which of the following food recommendations should the nurse make? - ANSWER ==Broccoli
Yogurt
Cream cheese
Clients who take phenelzine, an MAOI, should not eat foods that contain tyramine.
Broccoli, yogurt, and cream cheese do not contain tyramine.
A nurse is assessing an older adult client who has pneumonia. Which of the following
findings should the nurse expect? - ANSWER ==Acute confusion
An older adult client who has pneumonia will also typically have acute confusion,
fatigue, lethargy, and anorexia.
A nurse is providing teaching about home care to the parents of a child who has autism
spectrum disorder. Which of the following instructions should the nurse include? -
ANSWER ==Use a reward system to modify the child's behavior
A nurse is preparing to administer lactated ringer's 1,500 mL IV to infuse at 50 mL/hr.
The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? - ANSWER ==13 gtt/min
A nurse is caring for a client following a vacuum-assisted birth. The nurse should monitor the client for which of the following complications related to vacuum-assisted birth? - ANSWER ==Cervical laceration
A nurse is assessing a client who has COPD. Which of the following findings should the
nurse expect? - ANSWER ==pH 7.31
Respiratory acidosis is an expected finding for a client who has COPD. The expected reference range of pH is 7.35 to 7.45. A pH level less than 7.35 indicated acidosis. For a client who has COPD a decrease in pH will be accompanied by an increase in the level of carbon dioxide over the expected reference range of 35 to 45, indicating respiratory acidosis.
A nurse is providing discharge teaching for the parents of a preschool age child who has a new prescription for amoxicillin/clavulanate suspension. Which of the following instructions should the nurse include in the teaching? SATA - ANSWER =="Shake the medication bottle well before each dose is given
"Store the medication in the refrigerator"
"Report diarrhea to the provider immediately"
A nurse is preparing a client for a paracentesis. Which of the following actions should
the nurse take? - ANSWER ==Instruct the client to void
A nurse is caring for a client who has active tuberculosis (TB). Which of the following actions should the nurse plan to take to prevent the transmission of the disease? - ANSWER ==Have the client wear a surgical mask while being transported outside the room
A nurse is caring for a client who has a deep-vein thrombosis. Which of the following actions should the nurse take? - ANSWER ==Instruct the client to elevate the affected extremity when sitting
The nurse should instruct the client to elevate the affected extremity to reduce edema
and facilitate venous return
A nurse is assessing a client who has a chest tube. Which of the following findings should the nurse expect? - ANSWER ==Occlusive dressing on the insertion site
Occlusive dressing on the insertion site prevents air from leaking and is an expected
finding
A nurse on an impatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. Which of the following
observations should the nurse identify as an indication for potential violence? -
ANSWER ==The client is pacing around the chair in which their partner is sitting
Hyperactivity and pacing indicates that this client is at risk for violent behavior. The nurse should assess the situation further and attempt to de-escalate the situation by speaking to the client in a low, calm voice using short sentences.
A nurse is caring for four clients. Which of the following tasks should the nurse delegate
to an AP? - ANSWER ==Arrange the lunch tray for a client who has a hip fracture
A nurse is caring for a client who has a prescription for chlorpromazine. Which of the
following findings should the nurse identify as an indication that the medication is
effective? - ANSWER ==Decreased hallucinations
Chlorpromazine is an antipsychotic medication administered to decrease hallucinations
and other manifestations of schizophrenia
A nurse is performing an abdominal assessment on a client. Identify the sequence of actions the nurse should take. - ANSWER ==Inspection
Auscultation
Percussion
Palpitation
A nurse is updating the plan of care for a client who is 48 hr postoperative following a
laryngectomy and is unable to speak. Which of the following actions should the nurse
plan to take first? - ANSWER ==Determine the client's reading skills
A nurse is planning care for a client who has rheumatoid arthritis. Which of the following
interventions should the nurse include in the plan? - ANSWER ==Increase the client's
dietary iron intake
Clients who have rheumatoid arthritis require food high in protein, vitamins, and iron to
promote tissue repair.
A nurse is caring for a client who has acute blood loss following a trauma. The client refuses a blood transfusion that might potentially save their life. Which of the following actions should the nurse take first? - ANSWER ==Explore the client's reasons for refusing the treatment
A nurse is caring for a group of clients. Which of the following clients should the nurse attend to first? - ANSWER ==An older adult client who is anxious and attempting to pull out an IV line
A nurse is preparing to teach about dietary management to a client who has Crohn's disease and an enteroenteric fistula. Which of the following nutrients should the nurse instruct the client to decrease in their diet? - ANSWER ==Fiber
To reduce diarrhea and inflammation
A nurse manager is preparing an educational session for nursing staff about how to provide cost-effective care. Which of the following methods should the nurse include in the teaching? - ANSWER ==Delegate non-nursing tasks to ancillary staff
A nurse is assessing a newborn following a vaginal delivery. Which of the following
findings should the nurse report to the provider? - ANSWER ==Nasal flaring
The nurse should report any indications of respiratory distress such as nasal flaring,
retractions, and grunting
A nurse is assessing a client who has decreased visual acuity due to cataracts. The nurse should identify that which of the following physiological changes is the cause for the client's visual loss? - ANSWER ==Increased opacity of the lens
A cataract is a cloudy or opaque area in the lens of the eye that inhibits light penetration
A nurse must recommend clients for discharge in order to make room for several critically injured clients from a local disaster. Which of the following clients should the nurse recommend for discharge? - ANSWER ==A client who has cellulitis and is receiving oral antibiotics every 8 hr
A nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. The nurse in unable to locate members of the client's family to obtain consent. Which of the following actions should the nurse take? - ANSWER ==Proceed with provision of medical care
A nurse is creating a plan of care for a newly admitted child. Which of the following
actions should the nurse include in the plan? - ANSWER ==Administer high-dose
antibiotic therapy
Children who have CF metabolize antibiotics more rapidly and require higher doses of
antibiotics to help fight aggressive infections
A nurse is providing teaching about lithium to a client who has bipolar disorder. Which of
the following statements should the nurse include in the teaching? - ANSWER
=="Notify your provider if you experience increased thirst"
The nurse should recognize that an increase in thirst is a manifestation of lithium toxicity. The nurse should instruct the client to report increased thirst, vomiting, diarrhea, or tremors to the provider.
A nurse is reviewing the ABG values of a client. The client has a pH of 7.2, PaCO2 of 60, and HCO3 of 25. The nurse should identify that the client has which of the following acid-base imbalances? - ANSWER ==Respiratory acidosis
A client who has respiratory acidosis will have a decreased pH below the expected reference range of 7.35, and increased PaCO2 above the expected reference range of 35 to 45, and an HCO3 within the expected reference range of 22 to 26.
A nurse is providing teaching about advance directives to a middle adult client. Which of the following client responses indicates an understanding of the teaching? - ANSWER =="I can designate my partner as my health care surrogate"
A charge nurse notices that one of the nurses on the shift frequently violates unit policies by taking an extended amount of time for break. Which of the following statements should the charge nurse make to address this conflict? - ANSWER =="I would like to talk to you about the unit policies regarding break time"
A nurse manager is preparing to teach a group of newly licensed nurses about effective time management. Which of the following steps of the time management process should the nurse manager include as the priority? - ANSWER ==Making a list of activities to complete
A nurse is teaching about adverse effects with a client who is starting to take captopril.
Which of the following findings should the nurse identify as an adverse effect of the
medication to report to the provider? - ANSWER ==Cough
A home health nurse is caring for a group of older adult clients. The nurse should indicate a referral to the Program of All-Inclusive Care for the Elderly (PACE) for which of the following clients? - ANSWER ==A client whose caregiver requests adult day care services
PACE provides adult day care services along with in-home assessments and supportive
services
A nurse is assessing a client for compartment syndrome. Which of the following findings
should the nurse expect? - ANSWER ==Edema
Compartment syndrome causes increased pain, pallor, and paresthesias from
increased edema in the compartment involved
A nurse in an emergency department is caring for a child who has a fever and fluid-filled vesicles on the trunk and extremities. Which of the following interventions should the nurse identify as the priority? - ANSWER ==Initiate transmission-based precautions
The child most likely has varicella. Therefore, the nurse should isolate the child to
prevent the spread of the infection.
A nurse in an outpatient mental health facility is assessing a child who has autism spectrum disorder. Which of the following manifestations should the nurse expect? - ANSWER ==Strict adherence to routines
A nurse is caring for a client who recently signed an informed consent form to donate a kidney to her sibling who has end-stage kidney disease. The donator states to the nurse, "I don't want my brother to die, but what if I need this kidney one day?" Which of the following responses should the nurse make? - ANSWER =="You're afraid that your other kidney will fail at some point after the organ donation"
A nurse is preparing to administer a blood transfusion to a client. Which of the following procedures should the nurse follow to ensure proper client identification? - ANSWER ==Verify the client and blood product information with another licensed nurse
A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse include in the change of shift report? - ANSWER ==The time of the client's last dose of pain medication
A nurse is reviewing the laboratory report of a client who has end-stage kidney disease and received hemodialysis 24 hr ago. Which of the following laboratory values should the nurse report to the provider? - ANSWER ==Sodium 148 mEq/L
normal range: 135-145
Clients who have kidney disease often retain sodium and require sodium-restricted diets.
A nurse is caring for a client who has fluid volume overload. Which of the following tasks should the nurse delegate to an AP? - ANSWER ==Measure the client's daily weight
A nurse is caring for an older adult client who is experiencing chronic anorexia and is receiving enteral tube feedings. Which of the following laboratory values indicates that the client needs additional nutrients added to the feeding? - ANSWER ==Albumin 2.8 g/dL
The nurse should recognize that an albumin level of less than 3.5 indicates malnutrition
and a need for additional nutritional supplementation. The expected reference range for
albumin is 3.5-5
A home health nurse is evaluating a school age child who has cystic fibrosis. The nurse should initiate a request for a high-frequency chest compression vest in response to which of the following parent statements? - ANSWER =="My child has only a small amount of mucus after percussion therapy" [Show Less]