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ATI PN Comprehensive Predictor 2020
1. What are the key components of a respiratory assessment?
- A. Inspection, Palpation, Percussion, Auscultation
- B. Inspection, Observation, Auscultation, Percussion
- C. Auscultation, Palpation, Observation, Percussion
- D. Observation, Palpation, Percussion, Auscultation
Correct answer: A
Rationale: The correct answer is A: Inspection, Palpation, Percussion, Auscultation. A focused respiratory assessment involves inspecting the chest for symmetry and signs of distress, palpating for tenderness or abnormal masses, performing percussion to assess underlying tissues, and auscultating lung sounds. Choice B is incorrect as observation is a broad term that can encompass both inspection and palpation. Choice C is incorrect as auscultation is usually performed after inspection and palpation. Choice D is incorrect as observation should be more specific, and auscultation is a key component that is typically done last in a respiratory assessment.
2. What are the nursing interventions for a patient with fluid volume overload?
- A. Restrict fluid intake
- B. Monitor intake and output
- C. Administer diuretics as prescribed
- D. Elevate the head of the bed
Correct answer: A
Rationale: The correct nursing intervention for a patient with fluid volume overload is to restrict fluid intake. This helps to prevent further fluid accumulation in the body. Monitoring intake and output (choice B) is important to assess the patient's fluid balance but is not a direct intervention to address fluid volume overload. Administering diuretics as prescribed (choice C) is a medical intervention that may be ordered by a healthcare provider but should not be assumed as a nursing intervention without a prescription. Elevating the head of the bed (choice D) is a measure commonly used for patients with respiratory distress or to prevent aspiration but is not a direct intervention for fluid volume overload.
3. A client with peripheral arterial disease (PAD) is being taught about foot care by a nurse. Which of the following instructions should the nurse include?
- A. Apply lotion between the toes
- B. Wear shoes that fit properly
- C. Walk barefoot at home
- D. Apply ice to the feet daily
Correct answer: B
Rationale: The correct answer is B: 'Wear shoes that fit properly.' In peripheral arterial disease (PAD), it is crucial to wear shoes that fit well to prevent foot injuries. Choice A is incorrect because applying lotion between the toes can increase the risk of infection. Choice C is incorrect since walking barefoot at home can lead to injuries, especially in individuals with PAD. Choice D is incorrect as applying ice to the feet daily can further reduce blood flow to the extremities, worsening the condition in PAD.
4. A nurse in a provider's office is reinforcing discharge teaching with a client who is postoperative following cataract removal from one eye. Which of the following instructions should the nurse include?
- A. Use eye drops to soothe dryness
- B. Avoid rubbing the eye
- C. Sleep on the side of the affected eye
- D. Avoid lying on the affected side
Correct answer: D
Rationale: After cataract surgery, it is essential to avoid lying on the affected side to reduce pressure and promote healing. Sleeping on the side of the affected eye (Choice C) may increase pressure on the eye, leading to complications. While using eye drops to soothe dryness (Choice A) is generally recommended postoperatively, it is not as crucial as avoiding pressure on the eye. Rubbing the eye (Choice B) should be avoided to prevent irritation and potential damage, but it is not as critical as avoiding pressure on the affected eye.
5. How should a healthcare provider assess a patient with sepsis?
- A. Monitor vital signs and administer fluids
- B. Monitor for fever and administer antibiotics
- C. Check for tachycardia and elevated white blood cell count
- D. Administer fluids and provide nutritional support
Correct answer: A
Rationale: In sepsis, it is crucial to monitor vital signs to assess the patient's condition and administer fluids to maintain circulation. This approach helps in stabilizing blood pressure and perfusion. While monitoring for fever and administering antibiotics (choice B) is important in managing sepsis, the initial priority lies in assessing and stabilizing the patient's hemodynamic status. Checking for tachycardia and elevated white blood cell count (choice C) can be part of the assessment but does not encompass the immediate intervention needed in sepsis. Administering fluids and providing nutritional support (choice D) are essential in managing sepsis, but the primary step should be to assess the patient's condition through vital sign monitoring.
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