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ATI PN Comprehensive Predictor 2023 Quizlet
1. A nurse is reviewing the plan of care for a client who is receiving oxygen therapy. Which of the following interventions should the nurse include to prevent complications?
- A. Check the client's oxygen saturation every 2 hours
- B. Provide humidified oxygen
- C. Instruct the client to perform deep breathing exercises
- D. Use an oxygen mask for delivery
Correct answer: B
Rationale: The correct answer is B: Provide humidified oxygen. Providing humidified oxygen helps prevent dryness and irritation of the respiratory tract during oxygen therapy. This intervention is crucial in preventing complications such as mucous membrane dryness and potential damage to the airways. Checking the client's oxygen saturation every 2 hours (choice A) is essential for monitoring the client's response to therapy but does not directly prevent complications. Instructing the client to perform deep breathing exercises (choice C) is beneficial for respiratory function but does not directly address preventing complications related to oxygen therapy. Using an oxygen mask for delivery (choice D) is a common method of administering oxygen but does not specifically focus on preventing complications like dryness and irritation.
2. Which term specifically refers to positive actions taken to help others?
- A. Beneficence
- B. Justice
- C. Autonomy
- D. Non-maleficence
Correct answer: A
Rationale: The correct answer is A, 'Beneficence.' Beneficence is the ethical principle that involves taking positive actions to help others. Choice B, 'Justice,' pertains to fairness and equity in treatment, not specifically positive actions. Choice C, 'Autonomy,' relates to respecting individuals' rights to make their own decisions, not necessarily taking actions to help others. Choice D, 'Non-maleficence,' focuses on the obligation to avoid causing harm rather than actively helping others.
3. What are the nursing interventions for a patient receiving anticoagulant therapy?
- A. Monitor INR levels and check for bleeding
- B. Administer antiplatelet therapy
- C. Check for signs of DVT and provide anticoagulation
- D. Administer aspirin and monitor for bleeding
Correct answer: A
Rationale: The correct nursing intervention for a patient receiving anticoagulant therapy is to monitor INR levels and check for signs of bleeding. Monitoring the INR levels helps assess the effectiveness and safety of anticoagulant therapy, while checking for bleeding is essential due to the increased risk associated with anticoagulants. Choice B is incorrect as antiplatelet therapy is not the standard treatment for patients on anticoagulant therapy. Choice C is incorrect as providing additional anticoagulation is not a direct nursing intervention in this scenario. Choice D is incorrect because administering aspirin, an antiplatelet medication, along with anticoagulants can increase the risk of bleeding and is generally avoided.
4. What is the first step in managing a client with delirium?
- A. Administer sedative medication to calm the client
- B. Identify any reversible causes of delirium
- C. Limit environmental stimulation to reduce anxiety
- D. Administer antipsychotic medication to control behavior
Correct answer: B
Rationale: The correct first step in managing a client with delirium is to identify any reversible causes of delirium. This is crucial because addressing the underlying cause can help in resolving delirium more effectively. Administering sedative or antipsychotic medications without addressing the root cause may not be helpful and can even worsen the condition. Limiting environmental stimulation, although important, is not the primary step in managing delirium.
5. Which symptom would indicate a complication after a subdural hematoma?
- A. Increased appetite
- B. Decreased level of consciousness
- C. High-pitched cry
- D. Bulging posterior fontanelle
Correct answer: B
Rationale: A bulging posterior fontanelle is a sign of increased intracranial pressure in infants, not a common symptom after a subdural hematoma. In the context of a subdural hematoma, a decreased level of consciousness is more indicative of a complication as it can be a sign of worsening brain function due to increased pressure on the brain from the collection of blood in the subdural space. Increased appetite and high-pitched cry are not typically associated with complications of a subdural hematoma.
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