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ATI PN Comprehensive Predictor 2020
1. How should a healthcare provider respond to a patient experiencing a seizure?
- A. Protect the airway and monitor for post-ictal confusion
- B. Administer anticonvulsant medications
- C. Apply restraints to prevent injury
- D. Place the patient in a side-lying position
Correct answer: D
Rationale: When a patient is experiencing a seizure, the immediate priority is to ensure their safety by placing them in a side-lying position. This helps prevent aspiration in case of vomiting and maintains an open airway. Administering anticonvulsant medications is not within the scope of a healthcare provider's immediate response during a seizure. Applying restraints can potentially harm the patient by restricting movement and causing injury. Monitoring for post-ictal confusion is important after the seizure has ended, but the primary concern during the seizure is ensuring the patient's safety.
2. What is a key nursing action for a client with a wound infection?
- A. Change the dressing daily
- B. Perform a wound culture before applying antibiotics
- C. Cleanse the wound with alcohol-based solutions
- D. Apply a wet-to-dry dressing to the wound
Correct answer: B
Rationale: Performing a wound culture before applying antibiotics is crucial for determining the specific type of infection present and selecting the most effective antibiotic treatment. Changing the dressing daily (Choice A) is a routine wound care practice but may not address the root cause of the infection. Cleansing the wound with alcohol-based solutions (Choice C) can be too harsh and delay wound healing. Applying a wet-to-dry dressing (Choice D) is an outdated practice that can cause trauma to the wound bed and hinder the healing process.
3. A nurse is assisting with the admission of a client who has major depressive disorder. Which of the following communication techniques should the nurse use to establish a trusting relationship with the client?
- A. Offer medical advice
- B. Offer general leads
- C. Ask open-ended questions
- D. Use assertive communication
Correct answer: B
Rationale: In the context of establishing a trusting relationship with a client who has major depressive disorder, offering general leads is the most appropriate communication technique. General leads encourage clients to express themselves by providing subtle prompts or cues, which can help build rapport and trust. Offering medical advice (Choice A) is not suitable as it may come across as imposing and could hinder the establishment of trust. Asking open-ended questions (Choice C) is beneficial for eliciting detailed responses but may not be as effective at initially establishing trust as general leads. Using assertive communication (Choice D) can be perceived as aggressive and intimidating, which is not conducive to building a trusting relationship with a client who has major depressive disorder.
4. A nurse is teaching a client who has peripheral arterial disease (PAD) about exercise recommendations. Which of the following instructions should the nurse include?
- A. Exercise to the point of pain
- B. Stop exercising if pain occurs
- C. Exercise only once per week
- D. Avoid walking to prevent pain
Correct answer: B
Rationale: The correct instruction the nurse should include is to 'Stop exercising if pain occurs.' In peripheral arterial disease (PAD), it is crucial to avoid exercising to the point of pain as this may worsen the condition and lead to complications. Exercising to the point of pain can result in inadequate blood flow to the extremities, causing further damage. By stopping exercise if pain occurs, the client can prevent exacerbating their condition. Choices A, C, and D are incorrect because exercising to the point of pain, limiting exercise to once per week, and avoiding walking altogether are not recommended strategies for managing PAD and could potentially harm the client.
5. 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.
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