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ATI PN Comprehensive Predictor 2020 Answers
1. How should a healthcare professional assess a patient with suspected deep vein thrombosis (DVT)?
- A. Monitor for leg pain, swelling, and redness
- B. Check for calf tenderness and administer anticoagulants
- C. Check for discoloration and monitor oxygen saturation
- D. Check for numbness and provide thrombolytic therapy
Correct answer: A
Rationale: Correct Answer: The correct way to assess a patient with suspected deep vein thrombosis (DVT) is to monitor for leg pain, swelling, and redness. These are common clinical manifestations of DVT. Choice B is incorrect because administering anticoagulants should be based on a confirmed diagnosis, not just suspicion. Choice C is incorrect because discoloration and oxygen saturation are not primary indicators of DVT. Choice D is incorrect because numbness is not a typical symptom of DVT, and thrombolytic therapy is not the first-line treatment for suspected DVT.
2. A client is experiencing difficulty voiding following the removal of an indwelling catheter. What action should the nurse take to assist the client?
- A. Assess for bladder distention after 4 hours
- B. Pour warm water over the perineum
- C. Restrict the client's oral fluid intake
- D. Restrict movement for at least 12 hours
Correct answer: B
Rationale: The correct action for the nurse to assist the client who is experiencing difficulty voiding after the removal of an indwelling catheter is to pour warm water over the perineum. This technique can help stimulate urination by promoting relaxation of the perineal muscles and improving blood flow to the area. Assessing for bladder distention after 4 hours (Choice A) is important but not the immediate intervention needed to assist the client in voiding. Restricting the client's oral fluid intake (Choice C) can exacerbate the issue by reducing urine production. Restricting movement for at least 12 hours (Choice D) is unnecessary and may lead to discomfort and other complications.
3. A nurse is reviewing the plan of care for a client who is undergoing total parenteral nutrition (TPN). Which of the following interventions should the nurse include?
- A. Monitor the client's electrolyte levels daily
- B. Weigh the client daily
- C. Monitor the client's blood glucose levels every 6 hours
- D. Change the TPN tubing every 24 hours
Correct answer: D
Rationale: The correct intervention for the nurse to include in the plan of care for a client undergoing total parenteral nutrition (TPN) is to change the TPN tubing every 24 hours. Changing the tubing at regular intervals helps reduce the risk of infection associated with central venous catheters. Monitoring electrolyte levels daily (Choice A) is important but not specific to TPN. Weighing the client daily (Choice B) is important for monitoring fluid status but not directly related to TPN. Monitoring blood glucose levels every 6 hours (Choice C) is essential for clients receiving TPN, but changing the tubing is a more critical intervention to prevent infections.
4. A client with peptic ulcer disease is being taught measures to prevent exacerbation of the condition. Which of the following instructions should the nurse include?
- A. Avoid consuming dairy products
- B. Limit alcohol consumption
- C. Use antacids frequently
- D. Drink coffee to improve digestion
Correct answer: B
Rationale: The correct answer is B: Limit alcohol consumption. Alcohol can irritate the stomach lining and worsen peptic ulcer disease. Avoiding dairy products is not necessary unless the client is lactose intolerant. Using antacids frequently may provide symptomatic relief but does not address the root cause of the condition. Drinking coffee can actually stimulate acid production and potentially aggravate peptic ulcers.
5. A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk of injury for this client?
- A. Use a bed exit alarm system
- B. Raise all four side rails while the client is in bed
- C. Apply one soft wrist restraint
- D. Dim the lights in the client's room
Correct answer: A
Rationale: Using a bed exit alarm system is crucial in minimizing the risk of injury for a client with dementia. This intervention helps alert staff when the client is attempting to leave the bed, reducing the chances of falls. Raising all four side rails while the client is in bed (Choice B) can lead to restraint-related issues and is not recommended unless necessary for safety reasons. Applying a soft wrist restraint (Choice C) is generally not the first choice in managing clients with dementia due to the risk of complications and loss of mobility. Dimming the lights in the client's room (Choice D) may not directly address the risk of injury associated with dementia and may even increase the risk of falls due to poor visibility.
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