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ATI PN Comprehensive Predictor 2020 Answers
1. What is the correct way to assess for pitting edema?
- A. Press over the bony area for 5 seconds and release
- B. Press over the skin for 10 seconds and check for discoloration
- C. Press the area and check for the presence of rash
- D. Press the skin and assess for rebound tenderness
Correct answer: A
Rationale: The correct way to assess for pitting edema is to press over a bony area, typically the tibia, for 5 seconds and then release. This allows for the identification of pitting edema, characterized by an indentation that persists for a few seconds. Choice B is incorrect as pitting edema assessment does not involve checking for discoloration. Choice C is incorrect as the presence of a rash is not indicative of pitting edema. Choice D is incorrect as rebound tenderness is a different assessment used for abdominal conditions, not for pitting edema.
2. A nurse is planning care for a client who is receiving hemodialysis via an AV fistula. Which of the following interventions should the nurse include in the plan of care?
- A. Avoid taking blood pressures on the arm with the AV fistula.
- B. Check the fistula site daily for pallor.
- C. Place a warm compress over the fistula site every 4 hours.
- D. Keep the client's arm elevated on two pillows.
Correct answer: A
Rationale: The correct intervention is to avoid taking blood pressures on the arm with the AV fistula. This is crucial to prevent complications such as damage to the fistula. Checking the fistula site for pallor is not as important as avoiding blood pressures on the affected arm. Placing warm compresses over the fistula site is not recommended as it can increase the risk of infection. Keeping the client's arm elevated on two pillows is not necessary for the care of an AV fistula.
3. Which of the following is a key consideration when providing wound care for a client with a pressure ulcer?
- A. Cover the wound with a dry, sterile dressing
- B. Perform a wound culture before applying ointment
- C. Cleanse the wound with alcohol
- D. Cover the wound with a wet-to-dry dressing
Correct answer: B
Rationale: Performing a wound culture before applying ointment is crucial when providing wound care for a client with a pressure ulcer. This step helps identify the presence of any infection, allowing for appropriate treatment. Choice A is incorrect because covering the wound with a dry, sterile dressing may not address potential infections. Choice C is incorrect as cleansing the wound with alcohol can be too harsh and drying to the surrounding skin. Choice D is incorrect because covering the wound with a wet-to-dry dressing is not typically recommended for pressure ulcers, as it can cause trauma to the wound bed during removal.
4. A nurse is caring for a client who has been experiencing chronic pain. Which of the following interventions should the nurse implement?
- A. Provide the client with distractions such as television
- B. Administer pain medication around the clock
- C. Teach the client relaxation techniques
- D. Perform massage therapy on the client
Correct answer: C
Rationale: The correct intervention for a client experiencing chronic pain is to teach relaxation techniques. This helps the client manage pain more effectively by reducing stress and anxiety, which can contribute to the perception of pain. Providing distractions like television (Choice A) may offer temporary relief but does not address the underlying issue of chronic pain. Administering pain medication around the clock (Choice B) may lead to dependency and not promote holistic pain management. Massage therapy (Choice D) can be beneficial but may not be as effective as teaching relaxation techniques in the long term for managing chronic pain.
5. A nurse is reinforcing teaching with a client about the client's recent diagnosis of multiple sclerosis. The client states, 'I am very upset and I want to be alone for a little while.' Which of the following responses should the nurse make?
- A. I see that you are feeling overwhelmed. I will come back when you are ready
- B. This is normal, and I will check on you later
- C. You are feeling frustrated. Let's talk about your concerns.
- D. You will feel better soon. Let me get you some water.
Correct answer: A
Rationale: Acknowledging the client's feelings and allowing them space demonstrates understanding and respect for their emotions.
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