ATI Comprehensive Predictor 2020 – Chamberlain College of Nursing

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ATI Comprehensive Predictor 2020 – Chamberlain College of Nursing All_Documents_for_ATI_Comprehensive_Predictor 2020 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. 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? - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 138. What are the signs and symptoms of fluid volume deficit: loss of total body Na. Causes include vomiting, excessive sweating, diarrhea, burns, diuretic use, and kidney failure. Clinical features include diminished skin turgor, dry mucous membranes, tachycardia, and orthostatic hypotension. 139. What are the S/S of lithium toxicity?
(depakote for bipolar disorder): fine hand tremors, mild GI upset, slurred speech and muscle weakness 140. What are the therapeutic effects of protamine: Antidote to severe heparin overdose + Reversal of heparin administered during procedures 141. What are the values and beliefs that guide behavior and decision making?: Morals 142. What are total serum protein values (normals): 6-8 g/dL 143. What can prevent MI, stroke, or death in high-risk patients: Ramipril 144. What comorbidities may be observed with a patient who is bipolar?: Substance use disorder (experiences more rapid cycling), anxiety disorders, eating disorders, ADHD. 145. What does a newborns poop look like: If your baby is exclusively breastfed, her poop will be yellow or slightly green and have a mushy or creamy consistency 146. What do the nurse need to keep in mind about the client when being their advocate?: Client's religion & culture 147. What do you do when a client has a seizure: - lower to bed/floor - protect head, move nearby furniture, provide privacy, - - put on side with head flexed slightly forward, and loosen clothing to prevent injury
-in event of seizure, stay with client and call for help -admin meds as ordered
-note duration of seizure and sequence and type of movement 148. what foods should you avoid if you have diverticulitis?: avoid hard-to-digest foods such as nuts, corn, popcorn, and seeds, for fear that these foods would get stuck in the diverticula and lead to inflammation. (Eat foods high in fiber) 149. What immunizations are CONTRAINDICATED for pregnant women + which SHOULD be given?: Contraindicated = Herpes Zoster + Varicella + MMR (measles, mumps, rubella) Should give = TDaP (Tetanus, Diphtheria, Pertussis) 150. What is an agreement to keep promises: Fidelity 151. What is an interdisciplinary team?: A group of health care professionals from different disciplines 152. what is a normal hematocrit level in a female?
What are normal Hgb values (female)?
what are normal values for WBCs?: 37-48% (male is 42-52%) 12-16 g/dL (male 13-17)
4500-11,000 / uL 153. What is appropriate for an adolescent in the hospital?: Puzzles and books 154. What is avoidance of harm or injury: Non-maleficence 155. What is bipolar disorder?: Bipolar disorder is a mood disorder with recurrent episodes of depression and mania. 156. What is fairness in care delivery and use of resources: Justice 157. what is important about the diet of someone taking ACE inhibitors?: can result in high potassium levels. Limit potassium intake (beans, spinach, potatoes, dried apricots, acorn squash, yogurt, salmon, avocados, mushrooms and bananas) 158. what is normal pre-albumin values?
what are normal serum levels of magnesium ?
what is a normal potassium serum level?: 17-40 mg/dL 1.5-2.5 mEq/L (less than 1.5 is considered hypomagnesemia) 3.5-5.0 mEq/L (less than 3.5 is considered hypokalemia) 159. What is the difference between respiratory acidosis and respiratory alkalosis?: Acidosis refers to an excess of acid in the blood that causes the pH to fall below 7.35, and alkalosis refers to an excess of base in the blood that causes the pH to rise above 7.45. 160. What is the most appropriate method for contraception for an adolescent: IUD or implant 161. What is the nurse's contribution to an interdisciplinary team?: - knowledge of nursing care & its management
- a holistic understanding of the client, her/his healthcare needs & healthcare systems. 162. What is the nursing action for dehiscence: Cover with a sterile towel moistened with sterile saline; Have patient flex knees slightly and put in Fowler's . 163. What is the process of taking a telephone order from a provider?: Patient name, drug, dose, route, frequency read back for accuracy 164. What is the proper nutrition during pregnancy: - Folic acid is important for pregnancy, as it can help to prevent birth defects known as neural tube defects, including spina bifida
- green leafy vegetables and brown rice 165. What is the right to make ones own personal decisions, even tho those decisions might not be in the persons best interest: Autonomy 166. What is the safest way to thaw out frozen foods: In the refrigerator 167. What is the study of conduct and character?: Ethics 168. What kind of medications are indicated for abstinence maintenance of alcohol?: Disulfiram (Antabuse), Naltrexone (Vivitrol), Acamprosate (Campral) 169. What medications can be taken to help with smoking cessation: Bupropion hydrochloride is a medicine for depression, but it also helps people quit smoking. Brand names include Zyban®, Wellbutrin®, Wellbutrin SR® and Wellbutrin XL® but this medication is also available as a generic. Varenicline (chantix) 170. What position is good to use for a patient who is at high risk for a pressure ulcer: 30 degree lateral position is recommended for clients at risk for pressure ulcers 171. What should be avoided during pregnancy: Do not take vitamin A supplements, or any supplements containing vitamin A (retinol), as too much could harm your baby 172. What should the nurse do when one member of a support group expresses anger repeatedly?: Focus more on the group members who have a positive outlook
(Speak to group member privately to uncover source of anger) 173. What temperature should pork be cooked at: 160 degrees 174. What therapy will be useful for patients with bipolar?: Electroconvulsive therapy for the patient who is suicidal or rapid cycling who HAS taken Lithium and has proven ineffective. Used to subdue manic behavior. 175. What to monitor for when taking enoxaparin (lovenox): Hyperkalemia Cases of headache, hemorrhagic anemia, eosinophilia, alopecia, hepatocellular and cholestatic liver injury reported 176. What type of infectious diseases are required to be reported to the health department?: - severe cases of Staphylococcus aureus infections including methicillin-resistant Staphylococcus aureus (MRSA) 177. What values would a nurse possess to be a client advocate?: - caring
- autonomy
- respect - empowerment 178. When caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate?
1. Cancer of any kind. 2. Impaired hearing.
3. Prescription drug intoxication. 4. Heart failure.: 3 179. When does Discharge planning begin?: At Admission 180. When performing nasotracheal suctioning what technique should be used?: Sterile asepsis bc the trachea is considered sterile and prevents infections 181. When providing family education for those who have a relative with Alzheimer's disease about minimizing stress, which of the following suggestions is most relevant?
1. Allow the client to go to bed four to five times during the day. 2. Test the cognitive functioning of the client several times a day.
3. Provide reality orientation even if the memory loss is severe. 4. Maintain consistency in environment, routine, and caregivers: 4 182. When should planning discharge process begin? a. at time of admission
b. 2 days after client is admitted
c. whenever the nurse has the time to do planning d. when the physician has the discharge order: A 183. When taking MAOI's, limit your consumption of: thyramine--it can cause elevated BP. This is found in "aged" products such as aged cheeses (swiss), cured meats (pepperoni/salomi), sauerkraut, soy sauce...Examples of MAOI's are: Isocarboxazid (Marplan), Phenelzine (Nardil), Selogilive, Emsam, Eldepryl, Zelapar... 184. When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse's actions during this
intervention?
1. The restraints/seclusion policies set forth by the institution. 2. The patient's competence.
3. The patient's voluntary/involuntary status. 4. The patient's nursing care plan.: 3 185. Where should the cath bag be placed when urinary catheterization: Make sure the catheter bag/system is at a level below the client's bladder to avoid reflux. 186. Which grief process is it when Client exhibits increased anxiety + may project anger toward self + others
"I don't deserve to die, this isn't fair": Anger stage 187. Which Grief Process when Client acknowledges the impending loss while remaining hopeful
"If I could just make it through this, I'd never smoke again": Bargaining Stage 188. Which of the following assessment findings would indicate to the nurse the need for more sedation in a client who is withdrawing from alcohol
dependence?
1. Steadily increasing vital signs. 2. Mild tremors and irritability.
3. Decreased respirations and disorientation. 4. Stomach distress and inability to sleep.: 1 189. Which of the following is a correctly stated nursing diagnosis for a client
with abruptio placentae?
1. Infection related to obstetrical trauma. 2. Potential for fetal injury related to abruptio placentae. 3. Potential alteration in tissue perfusion related to depletion of fibrinogen.
4. Fluid volume deficit related to bleeding.: 4 190. Which of the following is a realistic short-term goal to be accomplished in 2 to 3 days for a client with delirium?
1. Explain the experience of having delirium.
2. Resume a normal sleep-wake cycle. 3. Regain orientation to time and place.
4. Establish normal bowel and bladder function.: 3 191. Which of the following is essential when caring for a client who is experiencing delirium?
1. Controlling behavioral symptoms with low-dose psychotropics. 2. Identifying the underlying causative condition or illness. 3. Manipulating the environment to increase orientation.
4. Decreasing or discontinuing all previously prescribed medications.: 2 192. Which of the following nursing interventions is MOST important for a
45-year-old woman with rheumatoid arthritis?
1. Provide support to flexed joints with pillows and pads. 2. Position her on her abdomen several times a day. 3. Massage the inflamed joints with creams and oils.
4. Assist her with heat application and ROM exercises.: 4 193. Which of the following should indicate to a nurse the need to suction a client's tracheostomy? a) irritability
b) hypotension c) flushing
d) bradycardia: A 194. Which of the following situations can be identified as an ethical dilemma?
A. A nurse on a med surge unit demonstrates signs of chemical impairment
B. A nurse over hears another nurse telling an older adult client that if he doesnt stay in bed she will restrain him C. A family has conflicting feelings about the initiation of enteral tube feedings of their father who is terminally ill D. A client who is terminally ill hesitates to name her spouse on her durable power of attorney form: C 195. Which of the following techniques should the nurse use when performing nasotracheal suctioning for a client? a) insert the suction catheter while the client is swallowing
b) apply intermittent suction when withdrawing the catheter
c) place the catheter in a location that is clean and dry for later use d) hold the suction catheter with the clean, non-dominant hand: B 196. Which outcome indicates effective client teaching to prevent constipation? a) The client reports engaging in a regular exercise regimen.
b) The client limits water intake to three glasses per day.
c) The client verbalizes consumption of low-fiber foods. d) The client maintains a sedentary lifestyle.: A [Show More]

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