ATI Predictor Comprehensive Assessment 2019 A

1. A nurse is caring for a client who has major depressive disorder. The client tells the nurse, “No one cares about me. I’m completely alone”. Which of the following responses should the nurse make?

1. “What makes you think that”?
2. “Can you give me an example of how others are making you feel this way?”
3. “You should join a community support group.”
4. “Don’t worry. You should be feeling better in a couple weeks.”

1. A nurse on a medical-surgical unit is caring for a client who states that she plans to leave the facility against medical advice. For which of the following actions by the nurse should the charge nurse intervene?

b. Asks the client to sign a form releasing the hospital from legal responsibility c.        Asks security to detain the client until the provider is notified

1. Show the client for abnormal laboratory results
2. Asks the client what her plans are for follow-up care

 

1. A nurse is a prenatal teaching to a client who is at 12 weeks of gestation. The nurse should tell the client she will undergo which of the following screening tests at 16 weeks of gestation?

1. Maternal serum alpha-fetoprotein
2. Nonstress test
3. Cervical cultures for chlamydia
4. Chorionic villus sampling

1. A nurse is admitting a client who has schizophrenia and experiences occasional auditory hallucinations. The client states, “It’s hard not to listen to the voices.” Which of the following questions should the nurse ask the client?

1. “Have you tried going to a private place when this occurs?”
2. “What helps you ignore what are you hearing?” d. “Do you understand that the voices are not real?”

e.     “Why do you think the voices are talking to you?”

 

 

1. A nurse is planning care for a client who sustained a major burn over 20% of the body. Which of the following interventions should the nurse include to support the client’s nutritional requirements?

b. Keep a calorie count for foods and beverages c.        Maintain calorie intake at 1,500 per day

1. Schedule meals at 6-hr intervals
2. Provide a low-protein, high-carbohydrate diet

1. A charge nurse is preparing to lead negotiations among nursing staff due to a conflict about overtime requirements. Which of the following strategies should the charge nurse use to promote effective negotiation?

1. Identify solutions prior to negotiation
2. Personalize the conflict
3. Attempt to understand both sides of the issue
4. Focus on how the conflict occurred

1. A nurse is preparing to administer a NG tube feeding to a school-age child. Which of the following actions should the nurse plan to take?

1. Position the child at a 10 to 20 degree angle after feeding
2. Warm the formula in the microwave
3. Complete the feeding in 5 min
4. Measure the tubing from the nose to the distal port

1. A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan?

1. Monitor the FHR via Doppler every 30 min
2. Measure the clients urine output every hour
3. Restrict the clients total fluid intake to 250mL/hr
4. Give the client protamine if signs of magnesium sulfate toxicity occur

 

1. A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first?

1. Notify the provider
2. Measure the clients vital signs
3. Report the incident to the nurse manager
4. Fill out an incident report

1. A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first?
   1. Notify the provider
   2. Measure the clients vital signs
   3. Report the incident to the nurse manager
   4. Fill out an incident report
2. A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include?

1. Increased urinary frequency
2. Dry cough
3. Excessive sweating
4. Metallic taste in the mouth

1. A nurse is caring for a client who is postoperative and has a chest tube drainage system. For which of the following findings should the nurse notify the provider?

1. Tidaling occurs when the client is breathing
2. Continuous bubbling in the water seal chamber
3. Oxygen saturation of 92% on room air
4. Presence of 50 mL/hr in the drainage chamber

1. A nurse is preparing to administer vancomycin IV to an adult. The client asks the nurse if the medication can be given 2 hr earlier. Which of the following statements should the nurse make?

1. “I can infuse the medication at a faster rate.”
2. “I have up to 2 hours after the usual schedule time to give you this medication.”
3. “I can adjust the time and schedule for when it’s convenient for you.” e.            “I can start the medication 30 min earlier.”

1. A nurse in the emergency department is interviewing a client immediately following a sexual assault. Which of the following actions should the nurse take first?

1. Determine a clients current anxiety level
2. Initiate a referral for client counseling
3. Request the clients permission to contact a family member
4. Report the clients assault to the authorities

1. A nurse is caring for a client who gestational hypertension and is experiencing toxic effects due to magnesium sulfate therapy. The nurse should anticipate administering which of the following medications?

1. Sodium bicarbonate
2. Potassium chloride d. Calcium gluconate

 

e.     Magnesium sulfate

1. A nurse is caring for a client who has end-stage kidney disease. The client’s adult child asks the nurse about becoming a living kidney donor for their parent. Which of the following conditions in the child’s medical history should the nurse identify as a contraindication to the procedure?

1. Hypertension
2. Osteoarthritis
3. Primary glaucoma
4. Amputation

1. A nurse has identified tasks to delegate to a group of assistive personnel (AP) after receiving change-of-shift report. Identify the sequence of steps the nurse should follow when delegating tasks to the Aps. Put in order

-Review the skill level and qualifications of each AO

-Monitor progress of tasks completion with each AP

-Evaluate the APs’ performance of each task

-Communicate appropriate tasks to the Aps with specific expectations

1. A nurse is preparing to perform sterile wound irrigation and dressing change for a client. Which of the following actions by the nurse indicates a break in surgical aseptic technique?

1. Applying a sterile gown after applying a sterile mask
2. Putting on sterile gloves after preparing the sterile field
3. Placing the supplies on the sterile field and leaving a 1-inch perimeter e.        Balancing the bottle on the sterile basin while pouring the liquid

1. A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase?

1. “Lets talk about how you can change your response to stress.”
2. “We should discuss resources to implement in your daily life.”
3. “Let me show you simple relaxation exercises to manage stress.” e.     “We should establish our roles in the initial session.”

1. A nurse is caring for a client who is receiving intermittent enteral tube feeding. Which of the following factors places the client at risk for aspiration?

1. A residual of 65 mL 1 hr postprandial
2. Receiving a high osmolality formula
3. Sitting in high-fowlers position during the feeding e.  A history of gastroesophageal reflux disease

1. A nurse is caring for a client who is 4 hr postpartum. The client reports an urge to void but is unable to void. Which of the following actions should the nurse take?

1. Administer a diuretic to the client
2. Massage the clients fundus
3. Encourage the client to attempt to void while using a sitz bath
4. Instruct the client to place her hands in cold water while attempting to void

 

1. A nurse is caring for a client who has preeclampsia and is experiencing a postpartum hemorrhage. The nurse should expect the provider to prescribe which of the following medications?

1. Carboprost
2. Methylergonovine
3. Nifedipine e.        Oxytocin

1. A nurse is providing teaching to the parents of a newborn about newborn genetic screening. Which of the following statements should the nurse include in the teaching?

1. “Your baby will be given 2 ounces of water to drink prior to the test.”
2. “This test wull be repeated when your baby is 2 months old.”
3. “This test should be performed after your baby is 24 hours old.”
4. “A nurse will draw blood from your baby’s inner elbow.”

1. A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching?

1. Placing a yellow bracelet on a client who is at risk for falls
2. Leaving a nasogastric tube clamped after administering oral medication
3. Documenting communication with a provider in the progress notes of the clients medical record
4. Administering potassium via IV bolus

1. A nurse is receiving change-of-shift report for a group of client. Which of the following clients should the nurse assess first?

1. A client who has diabetes mellitus and an HBA1c OF 6.8%
2. A client who has a hip fracture and a new onset of tachypnea
3. A client who ha sinus arrhythmia and is receiving cardiac monitoring
4. A client who has epidural analgesia and weakness in the lower extremities

1. A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse plan to take?

1. Obtain a 20 French indwelling urinary catheter
2. Hang the drainage bag on the side rails of the bed d. Secure the urinary catheter to the clients thigh

e.     Clean the tubing from the connection toward the meatus

1. A nurse is planning care for a group of client. Which of the following methods should the nurse use to manage time effectively?

1. Prioritize activities based on the nurses needs
2. Complete partial assessments on all the clients before planning the day
3. Use break time to perform documentation
4. Gather supplies prior to completing a dressing change

1. A nurse is preparing to assist the provider with a paracentesis for a client who has ascites. Which of the following actions should the nurse plan to take?

1. Have the client void prior to the procedure
2. Obtain the client weight every 15 min during the procedure
3. Place the client in a left side-lying position

 

1. Monitor the drainage to ensure no more than 2 L of fluid is removed

1. A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching?

1. “I should take antibiotics when I have a virus.”
2. “I can visit my nephew who has a chickenpox 5 days after the sores have crusted.”
3. “I should wash my hands for 10 seconds with hot water after working in the garden.”
4. “I can clean my cats litter box during my pregnancy.”

1. A nurse is caring for a school-age child who has sickle cell anemia and is in vaso- occlusive crisis. Which of the following actions should the nurse take?

1. Promote active range of motion exercises
2. Prepare for a transfusion of platelets
3. Apply cold compresses to the affected areas e.        Increase oral fluid intake

1. A nurse is assessing a client who is 2 hr postpartum for uterine atony. Which of the following actions should the nurse take?

1. Check the clients vital signs
2. Monitor the clients urinary output d. Palpate the clients fundus

e.     Evaluate the clients pain level

1. A nurse manager is reviewing documentation with a newly licensed nurse. Which of the following notations by the newly licensed nurse indicate an understanding of the teaching?

1. “OOB with assistance for breakfast.”
2. “Administered 8 u regular insulin sq.”
3. “Given 2 mg MSO4 IM for report of pain.”
4. “Dressing changed qd.”

1. A charge nurse is teaching new staff members about factors that increase a client’s risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence?

b. A history of being in prison c.        Previous violent behavior

1. Male gender
2. Experiencing delusions

1. A nurse is teaching a wellness class about depression for a group of older adult client. Which of the following information should the nurse include in the teahing?

1. Treatment options for depression are different for older adult clients than for clients in other age groups
2. Changes in sleep patterns are not a manifestation of depression in older adult clients d. Depression can be misdiagnosed as a neurocognitive disorder in older adult clients

e.     Higher dosages of antidepressants are required to achieve therapeutic effects in older adult clients

 

1. A nurse is assessing a client who is receiving morphine IV for pain. Which of the following findings should the nurse report the provider first?

1. BP 80/40 mm Hg
2. Pupil diameter 6 mm
3. Urinary Output 120/mL/4 hr
4. Bowel movement 5 days ago

1. A nurse is providing discharge teaching to a client who is postoperative following surgery for carpal tunnel syndrome. Which of the following statements by the client indicated an understanding of the teaching?

b. “I will need to keep my hand elevated above my heart for several days.” c.         “I should not use my affected hand for 4 to 6 weeks.”

1. “I should expect numbness and tingling in my hand.”
2. “I can apply heat for the first 24 hours to minimize the pain in my hand.”

1. A nurse is using an IV pump for a newly admitted client. Which of the following actions should the nurse take?

1. Check the cords of the IV pump for fraying
2. Ensure that the electric outlet has two prongs for the IV pump
3. Grasp the IV pump cord when unplugging it from the electrical outlet
4. Remove the safety inspection sticker before plugging in the IV pump

1. A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan?

1. Maintain the client on bed rest
2. Provide total care in performing the clients ADLs
3. Place the client left arm on a pillow while he is sitting
4. Place food on the left side of the clients mouth when he is ready to eat

1. A nurse on a pediatric unit is preparing to insert an IV catheter for a 7-year-old child who is dehydrated. Which of the following actions should the nurse take?

1. Perform the procedure in the child’s room
2. Tell the child there will be discomfort during the catheter insertion
3. Require the parents to leave the room during the procedure
4. Use a mummy restraint to hold the child during the catheter insertion

1. A nurse is caring for a client who has acute glomerulonephritis. The nurse should identify that which of the following findings is the priority?

1. Hematuria
2. Weight gain of 3 kg (6.1 IB) d. BUN 24 mg/dL

e.     Fatigue

1. A nurse is assessing a client who is postoperative and has a history of pulmonary embolism. Which of the following findings is the priority for the nurse to report to the provider?

1. Tachycardia
2. Dry cough

 

1. Hypotension
2. Dyspnea

1. A nurse is reviewing the medical record of a client. Which of the following findings shouls the nurse report to the provider? EXHIBIT

1. Temperature
2. Bowel sounds
3. Prealbumin
4. Urine specific gravity

1. A nurse in the infectious disease division of the local health department is caring for a client. Which of the following infections should the nurse identify should be reported to the health department?

1. Chlamydia trachomatis
2. Human papilloma virus
3. Herpes simplex virus
4. Clostridium difficlle

1. A nurse in a family practice clinic is screening an adolescent client for idiopathic scoliosis. Which of the following assessments should the nurse perform as part of this screening?

1. Measure the truncal rotation
2. Observe for sacral dimpling
3. Measure the anteroposterior diameter of the chest
4. Observe for positive Romberg sign

1. A nurse is assessing an older adult client who had left-sided stroke. Which of the following findings should the nurse expect?

b. Loss of depth perception c.        Expressive aphasia

1. Left-sided weakness
2. Poor judgement

1. A nurse is preparing to teach the parents of a child who has cystic fibrosis. Which of the following instructions should the nurse plan to include?

b. Trim the fat from the red meat prior to cooking c.        Provide a diet high in protein and calories

1. Administer pancreatic enzymes 30 min after meals
2. Give the child hot foods to reduce the sense of fullness

1. A nurse is reviewing the medical records of four clients. The nurse should identify which of the following client findings requires follow-up care?
   1. A client who received a Mantoux test 48 hr ago and has an induration
   2. A client who is taking bumetanide and has a potassium level of 3.6 mEq/L
   3. A client who is taking warfarin and has an INR of 1.8
   4. A client who is scheduled for a colonoscopy and is taking sodium phosphate
2. A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include?

1. Increase intake of foods high in gluten

 

1. Sweeten foods with fructose corn syrup
2. Increase intake of milk products e.        Consume foods high in bran fiber

1. A nurse is planning care for a client who has an L4 spinal cord injury. Which of the following interventions to prevent skin breakdown should the nurse include in the plan of car?
   1. Ask the client to shift his weight every 20 min while sitting in a chair
   2. Provide a high-fiber diet for the client
   3. Maintain the head of the bed at a 45 degree angle
   4. Massage reddened areas over bony prominences
2. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained verbal prescription for mechanical restraints. Which of the following actions should the nurse take?

1. Document the clients condition and behavior every 25 min
2. Request a renewal of the prescription every 8 hr
3. Assess the clients peripheral pulse rate every 30 min
4. Obtain a written prescription for the restraints within 4 hr

1. A nurse is teaching a guardian of an adolescent who has mild persistent asthma and a new prescription for maintenance prednisone. Which of the following statements by the guardian indicated an understanding of the teaching?

b. “I should give this medication to my son when he starts to wheeze.” c. “This medication can increase my son’s risk for infection

1. “I should have my son take this medication between meals.”
2. “My son should avoid grapefruit juice while on this medication.”

1. A charge nurse is teaching a group of newly licensed nurses about the correct use of restraints. Which of the following examples should the charge nurse include in the teaching?

1. Applying elbow immobilizers on an infant recovering from cleft lip surgery
2. Placing a belt restraint on a school-age child who has seizure
3. Keeping the side-rails of a toddlers crib elevated
4. Securing wrist restraints to the bed rails for an adolescent

1. A nurse is reviewing assessment data from several clients. For which of the following clients should the nurse recommend referral to a dietician?

b. A client who has an albumin level of 3.7 g/dL c.               A client who has a on a nonhealing leg ulcer

1. An older adult client who has presbyopia
2. An older adult client who has a BMI of 24

1. A nurse is assessing a client who is 1 day postoperative following the placement of an ileostomy. Which of the following findings should the nurse report to the provider?

1. Blood is present in the output
2. The output is a dark green liquid
3. The stoma bleeds slightly when touched e.      The stoma has a purplish hue

 

1. A nurse is caring for a client who is obese. The client is crying and states, “Everyone is staring at me because of my weight.” Which of the following responses should the nurse make?

1. “It sounds like you’re saying that you feel comfortable around others.”
2. “Let’s discuss some weight loss strategies that might work for you.”
3. “How long have you struggled with your weight?”
4. “Have you always felt uncomfortable being overweight?”

1. A nurse is preparing educational material for a client. Which of the following techniques should the nurse use in creating the material?

1. Use words with three or four syllables
2. Avoid using cartoons in the teaching material
3. Emphasize important information using bold lettering
4. Write information at a seventh-grade reading level

1. A nurse is caring for a client who has a new prescription for warfarin. When reviewing the client’s current medication, which of the following medications should the nurse identify as contraindicated for use with warfarin? (Select All That Apply)

1. Ibuprofen
2. Magnesium sulfate
3. Cetirizine
4. Gingko biloba h. Aspirin

1. A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include un the teaching?

1. Take magnesium hydroxide for indigestion
2. Drink at least 3 L of fluid daily
3. Consume foods high in potassium e.    Eat 1 g/kg of protein per day

1. A nurse is performing gastric lavage for a client who has upper gastrointestinal bleeding. Which of the following actions should the nurse take?

b. Instruct the client to lie on his right side c.          Insert a large-bore NG tube

1. Instill 500 mL of solution through the NG tube
2. Use a cold irrigation solution

1. A nurse is reading a tuberculin skin test for a client who received a purified protein derivative test 72 hr ago. Which of the following findings indicates a positive test?

b. A reddened area measuring 5 mm c.      An induration measuring 10 mm

1. A reddened area measuring 10 mm
2. An induration measuring 5 mm

1. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor which of the following complications?

1. Contractions

 

1. Vomiting
2. Epigastric pain
3. Hypertension

1. A nurse is reviewing the medication administration record of a client. Which of the following prescriptions should the nurse clarify?

b. Acetaminophen 650 mg PO Q 6 hours c.        Digoxin .250 PO daily

1. Ceftriaxone 1 g IV Q 24 hours
2. Levothyroxine 75 mcg PO daily at 0600

1. A nurse is caring for a client who is at 38 weeks of gestation, is in active labor, and has ruptured membranes. Which of the following actions should the nurse take?

1. Initiate fundal massage
2. Apply a fetal heart rate monitor
3. Initiate an oxytocin IV infusion
4. Insert an indwelling urinary catheter

1. A nurse is assessing a client who is receiving daily aspirin therapy. The nurse should identify that which of the following findings might indicate an allergic reaction to this medication?

1. Blurred vision
2. High blood pressure
3. Weight gain
4. Difficulty swallowing

1. A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine?

1. Hgb 14 g/dL
2. WBC count 2,900/ mm3
3. Heart rate 58/min
4. Fasting blood glucose 100 mg/dL

1. A nurse is providing teaching about crutch safety to a client. Which of the following client actions indicated an understanding of the teaching?

1. The client places the crutches 30 cm (12 in) to the front and side of each foot while standing
2. The client flexes her elbows 10 degrees when supporting weight by using the handgrips
3. The client keeps her axillae free of pressure
4. The client leans on both crutches to support body weight

1. A nurse is teaching a newly licensed nurse about incident reports. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

1. “They assist the facility to achieve benchmark goals.”
2. “They are mandatory government documentation.”
3. “They are used as a disciplinary tool for nurse evaluations.”

 

1. “They assist with unit quality improvement.”

1. A nurse is providing dietary teaching to a client who has chronic kidney disease. Which of the following instructions should the nurse include?

1. Increase dietary intake of sodium
2. Increase intake of high-potassium foods
3. Limit iron supplements
4. Restrict foods containing phosphorus

1. A nurse is caring for a group of clients who have chronic pain. Which of the following clients should the nurse identify as a candidate for occupational therapy?

b. A client who has Alzheimer’s disease and is experiencing abdominal pain c.     A client who has painful hands due to degenerative joint disease

1. A client who has migraines and is experiencing nausea and vomiting
2. A client who has a PCA for chronic pain following a laminectomy

1. A nurse is teaching a client who has chronic urinary tract infection. Which of the following instructions should the nurse include?

b. Take tub baths instead of showers c.      Drink at least 1 L of fluid everyday

1. Wipe from back to front after a bowel movement
2. Try to void every 4 hr

1. A nurse is speaking with the partner of a client who is the early stage of Alzheimer’s disease. The partner tells the nurse that she is able to manage the client’s physical care, but she doesn’t want to leave him alone while she travels for work. Which of the following referrals should the nurse make?

1. Restorative care
2. Hospice
3. Respite care
4. Rehabilitation facility

1. A nurse is caring for a client who is recovering from an amputation of her right arm below the elbow. Which of the following information should the nurse report to the occupational therapist?

1. The client has two small children at home
2. The client lives in a two-story home
3. The client is allergic to penicillin
4. The clients parent is in a skilled nursing facility

1. A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first?

 

1. Teach the client to keep the cast clean and dry
2. Place an ice pack over the cast
3. Position the casted extremity on a pillow e.        Palpate the pulse distal to the cast

1. A nurse is caring for a client following application of a cast. Which of the following action should the nurse Take First?
   1. Teach the client to keep the cast clean and dry.
   2. Place an ice pack over the cast.
   3. Position the casted extremity on a pillow. d. Palpate the pulse distal to the cast.
2. A nurse is preparing to assist with the lumbar puncture of an infant. The nurse should plan to place the infant in which of the following positions?
   1. Prone
   2. Trendelenburg d. Flexed side lying

e.     Seini fowler’s

1. Math question
2. A newly licensed nurse is unsure if an assigned task is within their scope of practice. Which of the following resources should the nurse consult?

1. Written prescri