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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 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 diagnosed with gout is receiving dietary instruction from a nurse. What dietary advice should be provided?
- A. Limit intake of fresh fruits and uncooked vegetables
- B. Limit intake of red meat and shellfish
- C. Limit intake of dairy products
- D. Increase intake of leafy greens
Correct answer: B
Rationale: The correct answer is to limit the intake of red meat and shellfish. These foods are high in purines, which can increase uric acid levels and trigger gout flare-ups. Fresh fruits, uncooked vegetables, dairy products, and leafy greens are generally not associated with exacerbating gout symptoms and do not need to be significantly restricted in the diet of someone with gout.
4. 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.
5. 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.
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