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ATI PN Comprehensive Predictor 2023 Quizlet
1. A nurse is caring for a client who is having difficulty voiding following the removal of an indwelling urinary catheter. Which of the following interventions should the nurse take?
- A. Assess for bladder distention after 6 hours
- B. Encourage the client to use a bedpan in the supine position
- C. Restrict the client's intake of oral fluids
- D. Pour warm water over the client's perineum
Correct answer: D
Rationale: The correct answer is to pour warm water over the client's perineum. This intervention can help stimulate voiding after catheter removal by promoting relaxation of the perineal muscles and increasing sensory input to the bladder. Assessing for bladder distention after 6 hours (Choice A) is important but not the initial intervention for difficulty voiding. Encouraging the client to use a bedpan in the supine position (Choice B) may not be effective in promoting voiding. Restricting the client's intake of oral fluids (Choice C) is not appropriate as hydration is important for urinary function.
2. How should a healthcare provider manage a patient with hypertensive crisis?
- A. Administer antihypertensive medications and monitor blood pressure
- B. Provide a high-sodium diet and fluid restriction
- C. Administer diuretics and provide oxygen therapy
- D. Provide IV fluids and monitor for kidney failure
Correct answer: A
Rationale: In a hypertensive crisis, the immediate goal is to lower blood pressure to prevent organ damage. Administering antihypertensive medications helps achieve this goal efficiently. Monitoring blood pressure is essential to assess the effectiveness of the treatment and adjust medication as needed. Providing a high-sodium diet and fluid restriction (Choice B) can exacerbate hypertension by increasing blood pressure. Diuretics and oxygen therapy (Choice C) are not the first-line treatment for hypertensive crisis, as the priority is rapid blood pressure reduction. Providing IV fluids and monitoring for kidney failure (Choice D) are not primary interventions for managing hypertensive crisis; the focus is on blood pressure control and organ protection.
3. What is the priority nursing action for a client with dehydration?
- A. Administer oral fluids
- B. Monitor electrolyte levels
- C. Administer antiemetics as needed
- D. Encourage bed rest
Correct answer: B
Rationale: The priority nursing action for a client with dehydration is to monitor electrolyte levels. Dehydration can cause imbalances in electrolytes such as sodium and potassium, affecting essential bodily functions. Monitoring electrolyte levels is crucial to promptly identify and correct any imbalances. While administering oral fluids (Choice A) is vital in treating dehydration, monitoring electrolyte levels takes precedence as it directly addresses the underlying imbalance. Administering antiemetics (Choice C) may be necessary for nausea and vomiting but is not the priority over electrolyte monitoring. Encouraging bed rest (Choice D) can conserve energy but is not as critical as monitoring electrolyte levels to prevent complications related to electrolyte imbalances.
4. A client is undergoing radiation therapy. Which of the following actions should the nurse take to prevent skin irritation?
- A. Apply heat packs to the area
- B. Use perfumed soap to cleanse the area
- C. Keep the area moist with lotion
- D. Avoid sun exposure to the treated area
Correct answer: D
Rationale: Avoiding sun exposure is crucial to prevent skin irritation and burns in clients undergoing radiation therapy. Radiation therapy makes the skin more sensitive to sunlight, increasing the risk of skin damage. Applying heat packs (choice A) can exacerbate skin irritation as heat can further irritate the skin that is already sensitive due to radiation. Using perfumed soap (choice B) can further irritate the skin due to its harsh chemicals, potentially worsening skin reactions. While keeping the area moist with lotion (choice C) may seem beneficial, some lotions contain ingredients that can worsen skin reactions during radiation therapy. Therefore, avoiding sun exposure to the treated area (choice D) is the most appropriate action to prevent skin irritation and damage during radiation therapy.
5. A nurse is teaching a client who is undergoing chemotherapy about measures to prevent infection. Which of the following instructions should the nurse include?
- A. Avoid crowded places
- B. Wear a mask at home
- C. Drink unfiltered water
- D. Avoid washing hands frequently
Correct answer: A
Rationale: The correct instruction the nurse should include is to advise the client to avoid crowded places. Immunocompromised clients undergoing chemotherapy are at a higher risk of infections, so avoiding crowded places can help reduce exposure to pathogens. Wearing a mask at home is not necessary unless someone in the household is sick. Drinking unfiltered water can introduce harmful bacteria, increasing the risk of infection. Avoiding washing hands frequently is incorrect as hand hygiene is crucial in preventing the spread of infections.
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