ATI Comprehensive Practice Predictor 2019 A

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A nurse is caring for a client who states, "My boss accused me of stealing yesterday. I was so angry I went to the gym and worked out." The nurse should recognize the client is demonstrating which of ... the following defense mechanisms? Correct Ans:- Sublimation (The client is exhibiting behaviors consistent with sublimation, which is displayed when a client substitutes socially unacceptable behavior for acceptable behavior.) A nurse is caring for a client who has generalized anxiety disorder and is to begin taking alprazolam. Which of the following actions should the nurse take? Correct Ans:- Initiate fall precautions for the client (The nurse should initiate fall precautions for a client who has a new prescription for alprazolam because common adverse effects associated with this medication are orthostatic hypotension, dizziness, confusion, and lethargy.) A nurse on a med surg unit is caring for a client prior to a surgical procedure. Which of the following findings should indicate to the nurse that the client has the ability to sign the informed consent? Correct Ans:- The client is able to accurately describe the upcoming procedure (The ability of the client to accurately describe the upcoming procedure indicates that the provider adequately informed the client and that the client is able to sign the informed consent) An assistive personnel (AP) and a nurse are turning a client onto the right side. Which of the following actions by the AP requires the nurse to intervene? Correct Ans:- Places a pillow under the client's right arm. (The AP should place a pillow under the client's left arm to prevent internal rotation of the left shoulder.) A nurse is providing dietary teaching to the parents of a 6-month-old infant. Which of the following instructions should the nurse include? Correct Ans:- Introduce new foods one at a time over 5 to 7 days. A nurse is caring for a client who has MRSA in an abdominal wound. Which of the following precautions should the nurse implement? Correct Ans:- Contact (The nurse should implement contact precautions for a client who has an infection spread by direct contact, such as MRSA.) A nurse is caring for a client who is 4 hr postpartum and has a boggy uterus with heavy lochia. Which of the following actions should the nurse take first Correct Ans:- Massage the uterus to expel clots (Using the EBP approach to client care, the nurse should identify that the priority action is massaging the client's uterus. Uterine massage will expel clots and increase uterine firmness, resulting in decreased bleeding.) A nurse is providing discharge teaching to a new parent about car seat safety. Which of the following statements should the nurse include in the teaching? Correct Ans:- "Secure the retainer clip at the level of your baby's armpits" A nurse is providing discharge teaching to a client who has colorectal cancer and a new colostomy. The client states, "I'm worried about being discharged because I live alone, and my insurance doesn't cover ostomy supplies. "Which of the following actions should the nurse take? (SATA) Correct Ans:- -Refer the client to a community based social workers -Initiate a consult with a home health care provider -Give the client information about local support groups (A social worker is necessary to help a client with self-care, as well as assist in locating agencies who can help the client face challenges with self-care and paying for necessary ostomy supplies. A home health nurse can assist the client in learning to care for the colostomy as well as provide medication management and emotional support. A client who has cancer and a new colostomy can get help with coping from a support group and possibly receive assistance obtaining supplies from local agencies) A nurse manager is reviewing unit records and discovers that client falls occur most frequently during the hours of 0530 and 0730. Which of the following actions should the nurse take when conducting a root cause analysis? Correct Ans:- Investigate environmental factors that might be contributing to client injury during these hours. (When conducting a root cause analysis, the nurse should look at the factors that could possibly lead to the clients' falls. This can include environmental factors that might be causing the problem.) A nurse is caring for a client who has terminal illness and requests lifesaving measures if a cardiac arrest occurs. Which of the following statements should the nurse make? Correct Ans:- "I will provide you with information about medical treatment to include in your living will" (The nurses' responsibility is to provide the client with information about specific instructions for addressing medical treatment in a living will. The nurse should assist the client while they are able to make decisions for themself by providing information about what end-of-life preferences to document.) A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse expect? Correct Ans:- Rapid speech (Clients who have delirium exhibit rapid, inappropriate, incoherent, and rambling speech patterns) A night shift nurse is giving a change of shift report to the day shift nurse on a client who is ready for discharge. Which of the following information is the priority for the nurse to communicate to the oncoming nurse? Correct Ans:- The client needs assistance when transferring from the bed to a wheelchair. (The greatest risk to this client is injury due to a fall. Therefore, the priority information for the nurse to communicate is that the client requires assistance during transfers.) A nurse is assessing a client during the immediate postpartum period. Which of the following findings requires immediate intervention by the nurse? Correct Ans:- Boggy uterus (When using urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a boggy uterus, which can indicate uterine hemorrhage. The nurse should [Show More]

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