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ATI PN Comprehensive Predictor 2020 Answers
1. What are the key components of a focused respiratory assessment, and how do you recognize signs of respiratory distress?
- A. Inspection, Palpation, Percussion, Auscultation
- B. Palpation, Inspection, Observation, Auscultation
- C. Percussion, Inspection, Auscultation, Palpation
- D. Inspection, Percussion, Auscultation, Palpation
Correct answer: A
Rationale: The correct answer is A: Inspection, Palpation, Percussion, Auscultation. A focused respiratory assessment should start with inspection (observing the breathing pattern), followed by palpation (feeling for abnormalities like crepitus), percussion (evaluating for dullness or hyperresonance), and auscultation (listening to lung sounds). This systematic approach helps to identify signs of respiratory distress, such as abnormal breath sounds, increased respiratory rate, use of accessory muscles, and cyanosis. Choices B, C, and D are incorrect because they do not follow the standard order and sequence of a focused respiratory assessment.
2. 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.
3. A client who has undergone vein ligation and stripping to treat varicose veins should be instructed to do which of the following activities during discharge teaching?
- A. Remain sedentary for 2-3 days
- B. Walk for 1-2 hours each day
- C. Wear compression stockings only at night
- D. Elevate legs while sitting
Correct answer: B
Rationale: The correct answer is B: 'Walk for 1-2 hours each day.' After vein ligation and stripping, walking helps promote circulation and aids in the recovery process. Option A is incorrect as remaining sedentary for 2-3 days can lead to decreased circulation and potentially increase the risk of complications. Option C is incorrect because compression stockings should typically be worn during the day to support circulation. Option D is incorrect as elevating the legs while sitting is beneficial, but walking is more effective in promoting circulation and recovery in this case.
4. 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.
5. A nurse is performing vision testing for a client following a head injury. Which of the following findings should the nurse identify as a problem with pupil accommodation?
- A. Pupils constrict when shifting gaze from near to far
- B. Pupils constrict when shifting gaze from far to near
- C. Lack of change in pupil size when shifting gaze from near to far
- D. Lack of change in pupil size when shifting gaze from far to near
Correct answer: D
Rationale: Pupil accommodation problems are indicated by the lack of change in size when shifting gaze from far to near. The correct answer is D because in pupil accommodation, the pupils should constrict when shifting gaze from far to near in order to adjust for near vision. Choices A and B describe normal responses of pupil constriction when shifting gaze, which do not indicate a problem. Choice C is incorrect as it describes a normal response of pupil size change when shifting gaze from near to far.
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