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ATI PN Comprehensive Predictor 2020 Answers
1. 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.
2. What are the complications of untreated deep vein thrombosis (DVT)?
- A. Pulmonary embolism and stroke
- B. Kidney failure and hypertension
- C. Liver failure and electrolyte imbalance
- D. Fluid overload and bradycardia
Correct answer: A
Rationale: Corrected Rationale: Untreated DVT can lead to complications such as pulmonary embolism and stroke. Pulmonary embolism occurs when a blood clot from the leg travels to the lungs, potentially blocking blood flow and causing respiratory distress. Stroke can occur if a blood clot dislodges from the leg veins, travels to the brain, and obstructs a blood vessel, leading to brain tissue damage. Both of these complications are life-threatening if not managed promptly. The other choices (B, C, D) do not represent common complications of untreated DVT and are therefore incorrect.
3. 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.
4. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displays toxicity. Which of the following actions should the nurse take?
- A. Position the client supine.
- B. Prepare an IV bolus of dextrose 5% in water.
- C. Administer methylergonovine IM.
- D. Administer calcium gluconate IV.
Correct answer: D
Rationale: In cases of magnesium sulfate toxicity, calcium gluconate is the antidote that should be administered promptly. Positioning the client supine (Choice A) is not the priority in this scenario. Administering dextrose 5% in water (Choice B) is not indicated for magnesium sulfate toxicity. Methylergonovine IM (Choice C) is used for postpartum hemorrhage, not for magnesium sulfate toxicity.
5. A client is prescribed simvastatin. Which instruction should the nurse provide during teaching?
- A. Take this medication in the morning.
- B. Avoid drinking grapefruit juice.
- C. Increase your intake of leafy green vegetables.
- D. Monitor your pulse daily while taking this medication.
Correct answer: B
Rationale: The correct answer is B: 'Avoid drinking grapefruit juice.' Grapefruit juice can increase the risk of toxicity when taken with simvastatin. Instructing the client to avoid grapefruit juice helps prevent this interaction. Choice A is incorrect because the timing of medication administration for simvastatin is usually in the evening. Choice C is unrelated to simvastatin therapy. Choice D is not necessary for monitoring while taking simvastatin.
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