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ATI PN Comprehensive Predictor 2023 Quizlet
1. 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.
2. When providing discharge instructions for a client with home oxygen, what safety measure should the nurse emphasize?
- A. Prohibit smoking near oxygen equipment
- B. Ensure the client uses non-flammable bedding
- C. Ensure oxygen tanks are stored upright
- D. Keep the oxygen equipment at least 6 feet away from heat sources
Correct answer: D
Rationale: The correct answer is to keep the oxygen equipment at least 6 feet away from heat sources. Placing oxygen equipment near heat sources can lead to fire hazards due to the oxygen's combustible nature. Option A is the correct safety measure as smoking near oxygen equipment can cause fires due to oxygen's flammable properties. Option B regarding the use of non-flammable bedding is not directly related to oxygen safety. Option C is important for proper oxygen tank functioning but is not as critical as keeping the equipment away from heat sources to prevent fires.
3. What is the recommended intervention for a patient experiencing severe hypoglycemia?
- A. Administer glucagon
- B. Provide a source of glucose
- C. Monitor blood sugar
- D. Assess vital signs
Correct answer: A
Rationale: Administering glucagon is the recommended intervention for severe hypoglycemia, especially when the patient is unconscious or unable to consume oral glucose. Glucagon helps increase blood glucose levels rapidly by stimulating the release of stored glucose from the liver. Providing a source of glucose (Choice B) can be challenging if the patient is unable to swallow or unconscious, making glucagon a more effective option. Monitoring blood sugar levels (Choice C) and assessing vital signs (Choice D) are important aspects of managing hypoglycemia but are not the immediate intervention for severe cases where prompt elevation of blood glucose levels is necessary.
4. A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client?
- A. Total bilirubin.
- B. Urine ketones.
- C. Serum potassium.
- D. Platelet count.
Correct answer: C
Rationale: The correct answer is C: Serum potassium. Spironolactone is a potassium-sparing diuretic, meaning it helps the body retain potassium. Therefore, the nurse should monitor the client's serum potassium levels to prevent hyperkalemia, which can be a potential side effect of spironolactone. Monitoring total bilirubin levels (A) is not specifically required for clients taking spironolactone. Urine ketones (B) are not directly influenced by spironolactone use. Platelet count (D) is not typically monitored in clients taking spironolactone.
5. A nurse is reinforcing discharge teaching with a client who is postoperative following an open radical prostatectomy. Which of the following instructions should the nurse include in the teaching?
- A. Perform Kegel exercises daily
- B. Perform light exercise for 3 hours each day
- C. Avoid bathing for 3 days
- D. Avoid sitting in a chair for more than 2 hours
Correct answer: A
Rationale: The correct answer is A: Perform Kegel exercises daily. After a radical prostatectomy, Kegel exercises are beneficial as they help strengthen the pelvic floor muscles, aiding in urinary control and recovery. Choice B is incorrect because recommending 3 hours of light exercise daily may not be suitable immediately postoperatively. Choice C is incorrect as personal hygiene, including bathing, is important for postoperative care. Choice D is incorrect because sitting for more than 2 hours does not specifically relate to the client's postoperative care needs.
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